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Therese Borden is the editor of CHEST Physician. After 20 years of research, writing, and editing in the field of international development and economics, she began working in the field of medical editing and has held a variety of editorial positions with the company. She holds a PhD in International Economics from American University, Washington, and a BA in history from the University of Washington, Seattle.
Burnout among surgical residents mitigated by traits of mindfulness
General surgery residents reported high levels of stress linked to burnout, but those who exhibited characteristics of mindfulness were less likely to experience this dynamic, a survey-based study has found.
Carter C. Lebares, MD, of the department of surgery at the University of California, San Francisco, and her colleagues wrote, “Stress is a double-edged sword, with a dose-response relationship between stress and performance described as an ‘inverted U-shaped curve.’ Although stress is initially stimulating, there is a tipping point when demands outstrip resources and stress becomes overwhelming,” the researchers wrote. Surgical trainees purposefully join a high-stress profession and presumably thrive on a demanding environment, but “that does not make individuals immune to the effects of overwhelming stress.”
The investigative team aimed to assess the prevalence and root causes of burnout among surgical trainees. They sent a survey questionnaire to 246 general surgery training program directors and asked them to distribute the survey to their residents (J Am Coll Surg. 2018 Jan;226[1]:80-90. doi: 10.1016/j.jamcollsurg.2017.10.010). The investigators focused on the components of burnout identified in the literature (emotional exhaustion, depersonalization, perceived stress, depression, anxiety, and alcohol misuse/abuse).
The survey, a voluntary and confidential exercise, was based on scales and tools to assess symptoms of burnout (Maslach Burnout Inventory), stress (Cohen’s Perceived Stress Scale), anxiety (Spielberger’s State Trait Anxiety Index), and depression/suicidal ideation (Patient Health Questionnaire).
The researchers also looked at personality traits that could make the difference between the usual stress of residency and burnout in individual trainees. Mindfulness was studied using the Cognitive Affective Mindfulness Scale–Revised. A personality characteristic “trait resilience” was captured in a 10-item Block Ego-Resiliency Scale, which measured ability to adapt to a demanding and changing environment. “Dispositional mindfulness, that is, the innate ability to pay attention to one’s thoughts, emotions, and experiences in a nonreactive way, has been shown to have a buffering effect against perceived stress and burnout among healthcare workers and trainees,” they wrote.
A total of 566 surgery residents responded to the survey; 51% were female and 76% were based in an academic training program. Overall, the survey found that burnout prevalence among general surgery residents was 69%, which confirms the findings of earlier studies of this population, and was significantly higher than rates seen in age-matched peers in the general population and among practicing surgeons. Burnout was equally prevalent among men and women, but men appeared more likely to experience depersonalization (62% vs. 51%). Emotional exhaustion was lower among lab trainees. Alcohol misuse and abuse was somewhat higher in women (58% vs. 41% and 40% vs. 26%, respectively). Although symptoms of burnout were not strongly associated with training level, PGY3 residents experienced the most (58% reported higher stress, 16% suicidal ideation, 50% high anxiety, and 61% alcohol abuse). A high level of stress was reported significantly less often by lab trainees, but alcohol misuse was significantly greater. A high level of stress and emotional exhaustion and depersonalization were strongly linked. And all of these elements were strongly associated with moderate to severe depressive symptoms, suicidal ideation, and high anxiety.
The study is limited by potential biases in the responses, inevitable in a voluntary, self-selected sample. The survey was sent to ACGME-accredited program directors who may or may not have distributed it to their trainees. The investigators suggested that whereas the findings of this study in general confirm earlier research on trainee burnout, the perception of lack personal accomplishment in this sample was less dominant in this sample. “Although this might be because we included residents in lab/research years (widely thought to be a time of very high productivity), it is more likely due to our use of an abbreviated (9-item) form of the Maslach Burnout Inventory-Human Services Survey” and therefore underreported the personal accomplishment factor.
The impact that personality traits (mindfulness and trait resilience) on burnout risk was notable in this sample. “Greater dispositional mindfulness was associated with an 85% decrease in the risk of high stress, and a greater trait resilience was associated with a 65% decrease in the risk of high stress.” Some individuals have traits to help them cope better with stress but the investigators stated that mindfulness and resilience can be taught and fostered in trainees.
The current research on burnout has identified both institutional factors and personal factors. This study suggests that strategies to address both, simultaneously, are needed to truly change the current burnout risk prevalence among surgical trainees. They concluded: “Our findings demonstrate that inherent mindfulness is already in use to combat stress and burnout in surgical trainees and, more importantly, it appears to work. Based on this evidence, mindfulness training can be a critical component of any intervention aimed at enhancing stress resilience and preventing or treating burnout in surgical trainees.”
The researchers reported no relevant financial conflicts.
SOURCE: J Am Coll Surg. 2018 Jan;226(1):80-90. doi: 10.1016/j.jamcollsurg.2017.10.010)
General surgery residents reported high levels of stress linked to burnout, but those who exhibited characteristics of mindfulness were less likely to experience this dynamic, a survey-based study has found.
Carter C. Lebares, MD, of the department of surgery at the University of California, San Francisco, and her colleagues wrote, “Stress is a double-edged sword, with a dose-response relationship between stress and performance described as an ‘inverted U-shaped curve.’ Although stress is initially stimulating, there is a tipping point when demands outstrip resources and stress becomes overwhelming,” the researchers wrote. Surgical trainees purposefully join a high-stress profession and presumably thrive on a demanding environment, but “that does not make individuals immune to the effects of overwhelming stress.”
The investigative team aimed to assess the prevalence and root causes of burnout among surgical trainees. They sent a survey questionnaire to 246 general surgery training program directors and asked them to distribute the survey to their residents (J Am Coll Surg. 2018 Jan;226[1]:80-90. doi: 10.1016/j.jamcollsurg.2017.10.010). The investigators focused on the components of burnout identified in the literature (emotional exhaustion, depersonalization, perceived stress, depression, anxiety, and alcohol misuse/abuse).
The survey, a voluntary and confidential exercise, was based on scales and tools to assess symptoms of burnout (Maslach Burnout Inventory), stress (Cohen’s Perceived Stress Scale), anxiety (Spielberger’s State Trait Anxiety Index), and depression/suicidal ideation (Patient Health Questionnaire).
The researchers also looked at personality traits that could make the difference between the usual stress of residency and burnout in individual trainees. Mindfulness was studied using the Cognitive Affective Mindfulness Scale–Revised. A personality characteristic “trait resilience” was captured in a 10-item Block Ego-Resiliency Scale, which measured ability to adapt to a demanding and changing environment. “Dispositional mindfulness, that is, the innate ability to pay attention to one’s thoughts, emotions, and experiences in a nonreactive way, has been shown to have a buffering effect against perceived stress and burnout among healthcare workers and trainees,” they wrote.
A total of 566 surgery residents responded to the survey; 51% were female and 76% were based in an academic training program. Overall, the survey found that burnout prevalence among general surgery residents was 69%, which confirms the findings of earlier studies of this population, and was significantly higher than rates seen in age-matched peers in the general population and among practicing surgeons. Burnout was equally prevalent among men and women, but men appeared more likely to experience depersonalization (62% vs. 51%). Emotional exhaustion was lower among lab trainees. Alcohol misuse and abuse was somewhat higher in women (58% vs. 41% and 40% vs. 26%, respectively). Although symptoms of burnout were not strongly associated with training level, PGY3 residents experienced the most (58% reported higher stress, 16% suicidal ideation, 50% high anxiety, and 61% alcohol abuse). A high level of stress was reported significantly less often by lab trainees, but alcohol misuse was significantly greater. A high level of stress and emotional exhaustion and depersonalization were strongly linked. And all of these elements were strongly associated with moderate to severe depressive symptoms, suicidal ideation, and high anxiety.
The study is limited by potential biases in the responses, inevitable in a voluntary, self-selected sample. The survey was sent to ACGME-accredited program directors who may or may not have distributed it to their trainees. The investigators suggested that whereas the findings of this study in general confirm earlier research on trainee burnout, the perception of lack personal accomplishment in this sample was less dominant in this sample. “Although this might be because we included residents in lab/research years (widely thought to be a time of very high productivity), it is more likely due to our use of an abbreviated (9-item) form of the Maslach Burnout Inventory-Human Services Survey” and therefore underreported the personal accomplishment factor.
The impact that personality traits (mindfulness and trait resilience) on burnout risk was notable in this sample. “Greater dispositional mindfulness was associated with an 85% decrease in the risk of high stress, and a greater trait resilience was associated with a 65% decrease in the risk of high stress.” Some individuals have traits to help them cope better with stress but the investigators stated that mindfulness and resilience can be taught and fostered in trainees.
The current research on burnout has identified both institutional factors and personal factors. This study suggests that strategies to address both, simultaneously, are needed to truly change the current burnout risk prevalence among surgical trainees. They concluded: “Our findings demonstrate that inherent mindfulness is already in use to combat stress and burnout in surgical trainees and, more importantly, it appears to work. Based on this evidence, mindfulness training can be a critical component of any intervention aimed at enhancing stress resilience and preventing or treating burnout in surgical trainees.”
The researchers reported no relevant financial conflicts.
SOURCE: J Am Coll Surg. 2018 Jan;226(1):80-90. doi: 10.1016/j.jamcollsurg.2017.10.010)
General surgery residents reported high levels of stress linked to burnout, but those who exhibited characteristics of mindfulness were less likely to experience this dynamic, a survey-based study has found.
Carter C. Lebares, MD, of the department of surgery at the University of California, San Francisco, and her colleagues wrote, “Stress is a double-edged sword, with a dose-response relationship between stress and performance described as an ‘inverted U-shaped curve.’ Although stress is initially stimulating, there is a tipping point when demands outstrip resources and stress becomes overwhelming,” the researchers wrote. Surgical trainees purposefully join a high-stress profession and presumably thrive on a demanding environment, but “that does not make individuals immune to the effects of overwhelming stress.”
The investigative team aimed to assess the prevalence and root causes of burnout among surgical trainees. They sent a survey questionnaire to 246 general surgery training program directors and asked them to distribute the survey to their residents (J Am Coll Surg. 2018 Jan;226[1]:80-90. doi: 10.1016/j.jamcollsurg.2017.10.010). The investigators focused on the components of burnout identified in the literature (emotional exhaustion, depersonalization, perceived stress, depression, anxiety, and alcohol misuse/abuse).
The survey, a voluntary and confidential exercise, was based on scales and tools to assess symptoms of burnout (Maslach Burnout Inventory), stress (Cohen’s Perceived Stress Scale), anxiety (Spielberger’s State Trait Anxiety Index), and depression/suicidal ideation (Patient Health Questionnaire).
The researchers also looked at personality traits that could make the difference between the usual stress of residency and burnout in individual trainees. Mindfulness was studied using the Cognitive Affective Mindfulness Scale–Revised. A personality characteristic “trait resilience” was captured in a 10-item Block Ego-Resiliency Scale, which measured ability to adapt to a demanding and changing environment. “Dispositional mindfulness, that is, the innate ability to pay attention to one’s thoughts, emotions, and experiences in a nonreactive way, has been shown to have a buffering effect against perceived stress and burnout among healthcare workers and trainees,” they wrote.
A total of 566 surgery residents responded to the survey; 51% were female and 76% were based in an academic training program. Overall, the survey found that burnout prevalence among general surgery residents was 69%, which confirms the findings of earlier studies of this population, and was significantly higher than rates seen in age-matched peers in the general population and among practicing surgeons. Burnout was equally prevalent among men and women, but men appeared more likely to experience depersonalization (62% vs. 51%). Emotional exhaustion was lower among lab trainees. Alcohol misuse and abuse was somewhat higher in women (58% vs. 41% and 40% vs. 26%, respectively). Although symptoms of burnout were not strongly associated with training level, PGY3 residents experienced the most (58% reported higher stress, 16% suicidal ideation, 50% high anxiety, and 61% alcohol abuse). A high level of stress was reported significantly less often by lab trainees, but alcohol misuse was significantly greater. A high level of stress and emotional exhaustion and depersonalization were strongly linked. And all of these elements were strongly associated with moderate to severe depressive symptoms, suicidal ideation, and high anxiety.
The study is limited by potential biases in the responses, inevitable in a voluntary, self-selected sample. The survey was sent to ACGME-accredited program directors who may or may not have distributed it to their trainees. The investigators suggested that whereas the findings of this study in general confirm earlier research on trainee burnout, the perception of lack personal accomplishment in this sample was less dominant in this sample. “Although this might be because we included residents in lab/research years (widely thought to be a time of very high productivity), it is more likely due to our use of an abbreviated (9-item) form of the Maslach Burnout Inventory-Human Services Survey” and therefore underreported the personal accomplishment factor.
The impact that personality traits (mindfulness and trait resilience) on burnout risk was notable in this sample. “Greater dispositional mindfulness was associated with an 85% decrease in the risk of high stress, and a greater trait resilience was associated with a 65% decrease in the risk of high stress.” Some individuals have traits to help them cope better with stress but the investigators stated that mindfulness and resilience can be taught and fostered in trainees.
The current research on burnout has identified both institutional factors and personal factors. This study suggests that strategies to address both, simultaneously, are needed to truly change the current burnout risk prevalence among surgical trainees. They concluded: “Our findings demonstrate that inherent mindfulness is already in use to combat stress and burnout in surgical trainees and, more importantly, it appears to work. Based on this evidence, mindfulness training can be a critical component of any intervention aimed at enhancing stress resilience and preventing or treating burnout in surgical trainees.”
The researchers reported no relevant financial conflicts.
SOURCE: J Am Coll Surg. 2018 Jan;226(1):80-90. doi: 10.1016/j.jamcollsurg.2017.10.010)
FROM JOURNAL OF THE AMERICAN COLLEGE OF SURGERY
Key clinical point: Burnout prevalence is high among surgical trainees, but individual traits such as mindfulness are linked to a lower risk of burnout.
Major finding: Among surgery residents, the total prevalence of burnout was 69%.
Study details: 566 responses to a voluntary and confidential survey of general surgery residents.
Disclosures: Investigators had no relevant financial disclosures.
Source: J Am Coll Surg. 2018 Jan;226(1):80-90. doi: 10.1016/j.jamcollsurg.2017.10.010.
Recommended Reading: Best of 2017
Recommended Reading lists are something of a tradition for ACS Surgery News. This feature has appeared several times over the years and it has always proved among the most popular items in the publication. But the project hinges on input from our Editorial Advisory Board, the members of which are already regularly called upon to help vet the publication’s content and give their advice. They have gone the extra mile and have once again chosen their “Best of 2017” studies in their own specialty areas, along with commentary on why their choices should be of interest to all surgeons. We hope our readers will find the list and the comments of interest.
General surgery
Cogbill TH et al. Rural general surgery: A 38-year experience with a regional network established by an integrated health system in the Midwestern United States. J Am Coll Surg. 2017;225(1):115-24.
This article is of particular interest because it provides details of an innovative, regional system of surgical care at the critical access hospitals and referral centers that cooperate seamlessly to improve quality of care and quality of practice for rural surgeons. It could serve as a model for similar independent hospitals and practices in a region to improve the practice lives of the surgeons in rural communities and preserve access to local care for rural patients.
Dimou FM et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: A propensity score analysis. J Am Coll Surg. 2017;224(4):502-14.This study is valuable because it sheds light on the current status of treatment of severe acute cholecystitis in the United States and reports outcomes of patients who get initial tube cholecystostomy. It demonstrates potential drawbacks of following the Tokyo Guidelines: fewer patients receiving definitive treatment (cholecystectomy) and higher mortality rates and readmissions.
Karen E. Deveney, MD, FACS 
Palliative Care
Gani F et al. Palliative care utilization among patients admitted for gastrointestinal and thoracic cancers. J Palliat Med. 2017 Nov 3; doi: 10.1089/jpm.2017.0295; epub ahead of print.
Is this a matter of “too little too late”? This retrospective cross-sectional analysis of patients identified in the National Inpatient Sample database admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer determined that only 8.5% of patients admitted received palliative care services. Surgical patients were 79% less likely to have received a palliative care consultation, and then only after a prolonged length of stay or postoperative complication. Is referral to palliative care services hindered by its stigmatization with these outcomes?
Taylor LJ et al. A framework to improve surgeon communication in high-stakes surgical decisions: Best Case/Worst Case. JAMA Surgery. 2017;152(6):531-8.
My chief used to say, “You might not be teachable, but you are trainable!” After surgeons received training in the Best Case/Worst Case framework described in this paper, they demonstrated that it was possible to successfully change the focus of decision-making conversations from an isolated surgical problem – with its menu of technical solutions – instead into a discussion about treatment alternatives and outcomes. This intervention is a useful tool for one of the most invasive procedures of all – an exploration of a patient’s preferences and values that is necessary for shared decision making within the acute setting.
Makhani SS et al. Cognitive impairment and overall survival in frail surgical patients. J Amer Coll Surg. 2017 Nov;225(5):590-600.
In my preoperative discussions with families of frail patients, it is often quite evident that the factor driving their decision is the cognitive state of the patient and the consequences of its further decline, even when they are willing to accept the risks of physical frailty. This study in a large multidisciplinary cohort of patients undergoing major operations determined that a combined frailty (Fried frailty score) and cognitive assessment score (Emory Clock Draw Test) has a more powerful potential to predict adult patients at higher risk of overall survival than does either measurement alone. Dual frailty and cognitive screening appears to be a promising adjunct to the shared decision-making process.
Geoffrey P. Dunn, MD, FACS 
Wilson DG et al. Patterns of care in hospitalized vascular patients at end of life. JAMA Surg. 2017;152(2):183-90.
This thoughtful study and the excellent accompanying invited commentary by William Schecter, MD, FACS, address a major, difficult issue that faces all physicians as our patients become older and sicker and our ability to keep them alive expands: How do we speak honestly with patients about their prognosis and likely outcomes and honor their autonomy in decision making?
Karen E. Deveney, MD, FACS
Practice Management
Robinson JR et al. Complexity of medical decision making in care provided by surgeons through patient portals. Surg Res. 2017;214:93-101.
This article describes an analysis of the content of patient portal messages exchanged between surgical providers and patients. The study demonstrates that more than 90% of these exchanges involved the delivery of medical care, and more than two-thirds of the messages contained medical decision making, which might have generated charges if done in a face-to-face outpatient encounter. The articles argues that surgeons are providing substantial medical care to their patients through patient portal message exchanges and suggests that models for compensation of this type of online care should be developed.
Gretchen Purcell Jackson, MD, FACS 
Vascular Surgery
Bennett KM et al. Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg. 2017 Sep;66(3):794-801.
This article uses the ACS NSQIP database to assess outcomes of women undergoing intervention for carotid stenosis in a real-world setting and finds that major adverse cardiac events in the first 30 days is higher for carotid artery stenting (12.2%), compared with carotid endarterectomy (5.2%). What we need to keep in mind is that the practice of any intervention for asymptomatic carotid stenosis is being reevaluated in the new CREST study, which will compare current best medical management with carotid stenting and carotid endarterectomy. The indications are likely to change for all, but because women had less relative risk reduction in the early studies, we can expect that the benefits for intervention for women will continue to be less than those for men, calling to question when we should truly intervene, and how best to do so.
Gargiulo M et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg. 2017 Oct;66(4);1065-72.
This study found that endovascular aneurysm repair, performed in patients with large necks (greater than 28 mm), was associated with further neck enlargement at 2 years, and a higher risk of proximal type I endoleak, with the need for reintervention. This is one of many recent studies, all with similar findings. The issue becomes how we can best address larger infrarenal necks, whether by use of fenestrated grafts, snorkels/chimneys with extension of the seal zone, aptus, or other technologies. The question of whether all grafts have equal impacts on these more dilated necks has still to be elucidated. Nonetheless, when we stretch the instructions for use, there is an increased likelihood for more interventions.
Zettervall SL et al. Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. J Vasc Surg. 2017 Oct;66(4):1305.
This study found that endografts with suprarenal fixation were associated with a greater decline in renal function, compared with those with infrarenal fixation, as well as with a longer length of stay. The reasons for the renal function decline are not entirely clear, and there was a slight increase in contrast use for those with suprarenal fixation but were otherwise similar when comparing comorbidities. Clearly, assessment of any impact on long-term renal function is important, and may affect future choice of endografts.
Linda Harris, MD, FACS
Bariatric Surgery
Rosenthal RJ et al. Obesity in America. Surg Obes Relat Dis. 2017 Oct;13(10):1643-50.
Although much has been reported on the dramatic benefits of bariatric surgery, it remains a matter of deep disappointment that only 1%-2% of the eligible population is receiving this life-saving therapy. This is a paper that reports and analyzes the results of a national survey that was conducted on behalf of the American Society for Metabolic & Bariatric Surgery, in an attempt to identify barriers to access, public misconceptions on obesity and its consequences, and other pertinent factors. Survey results included the findings that, although 80% of Americans considered obesity as the most serious health risk problem, there was a clear overestimation of the effectiveness of diet and exercise alone. The importance of this paper lies in the persistent lack of recognition and/or awareness of proven, safe, and durable medical and surgical options in the lay population, highlighting the importance of aligning efforts and resources toward educating both the public and referring physicians.
Adams TD et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017 Sep 21;377(12):1143-55
This paper reports the results of an observational, prospective study that followed patients who received gastric bypass, in comparison with a group of patients who desired but did not receive gastric bypass, and a third group of obese patients who did not seek surgery. The authors concluded that gastric bypass provided durable, 12-year remission and prevention of such lethal diseases as diabetes, hypertension, and dyslipidemia. The importance of this study is in its detailed follow-up, the exceedingly high retention rate of 90% at 12 years, and the comparisons made between surgical and nonsurgical groups, demonstrating not only the benefits of gastric bypass, but as importantly, the hazards of not receiving this treatment.
Schauer PR et al. Bariatric surgery versus intensive medical therapy for diabetes – 5-year outcomes. N Engl J Med. 2017 Feb 16;376(7):641-51.This paper is the latest installment of the long-term results from the STAMPEDE trial conducted at the Cleveland Clinic. STAMPEDE is a randomized, controlled trial that compared the best, most “intensive” medical therapy for type 2 diabetes vs. bariatric surgery (comprising a mix of gastric bypass and sleeve gastrectomy). Prior publications from this group reported 1- and 3-year results, and this paper reported the 5-year results, demonstrating the persistent superiority of bariatric surgery over the most rigorous intensive medical therapy in the resolution or improvement of hyperglycemia in patients with BMI ranges of 27 kg/m2 to 43 kg/m2. Of further significance was the fact that there were no major late surgical complications except for one reoperation.
Samer Mattar, MD, FACS 
Colon & Rectal Surgery
Jayne D et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: The ROLARR randomized clinical trial. JAMA. 2017;318(16):1569-80.
This trial of 471 rectal cancer patients demonstrated similar conversion rates for robotic (8.1%) and laparoscopic (12.2%) surgery. Of the other secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups.
Marshall JR et al. Laparoscopic lavage in the management of Hinchey grade III diverticulitis: A systematic review. Ann Surg. 2017;265(4):670-6.While there have been a number of groups using laparoscopic lavage in the setting of acute diverticulitis, including Hinchey grade III disease, several recent studies question this approach. This meta-analysis includes three recent randomized, controlled trials and analysis of 48 studies – demonstrating that rates of reintervention within 30 days to be 28.3% in the lavage group and 8.8% in the resection group. Other outcomes – including ICU admissions, 30- and 90-day mortality, or stoma rates at 12 months – were similar between groups.
Denost Q et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: The GRECCAR 5 randomized trial. Ann Surg. 2017;365(3):474-80.
While many studies have confirmed infectiveness of drainage after colectomy, there is still some controversy of the role of pelvic drainage after rectal surgery. A multicenter randomized, controlled trial with two parallel arms (drain vs. no drain) was conducted in 469 patients after rectal surgery for cancer. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Rates of pelvic sepsis were similar between drain and no drain: 16.1% vs. 18.0% (P = .58), and there was no difference in surgical morbidity, rate of reoperation, length of hospital stay, and rate of stoma closure between groups. Overall, this trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit.
Genevieve Melton-Meaux, MD, FACS
Breast Surgery
Giuliano AE et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 randomized clinical trial. JAMA. 2017 Sep 12;318(10):918-926.
Long-term outcomes from the practice-changing ACOSOG Z0011 (Alliance) trial confirming the safety of omitting completion axillary lymph node dissection in women with T1/T2 tumors treated by lumpectomy and whole-breast radiation when metastatic disease is identified in one or two sentinel nodes.
Masuda N et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017 Jun 1;376(22):2147-59.
Breast cancer patients that achieve a complete pathologic response after receiving neoadjuvant chemotherapy have a survival advantage, and patients found to have residual disease represent a higher-risk population subset. This prospective randomized clinical trial (known as the CREATE-X study) revealed that adjuvant capecitabine can significantly mitigate this risk, especially for patients with triple-negative breast cancer.
Curigliano G et al. De-escalating and escalating treatments for early stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol. 2017 Aug 1;28(8):1700-12.
This summary of the 2017 St. Gallen Conference proceedings provides a comprehensive yet concise review of contemporary standards of care in managing early stage breast cancer. Issues reviewed include lumpectomy margins, extent of breast/axillary surgery following neoadjuvant chemotherapy, options for breast radiation schedules following lumpectomy, and application of currently available gene expression profiles.
Troester MA et al. Racial differences in PAM50 subtypes in the Carolina Breast Cancer Study. J Natl Cancer Inst. 2018 Feb 1;110(2);doi: 10.1093/jnci/djx135; epub ahead of print (Aug 2017).
Breast cancer outcome disparities related to racial/ethnic identity are well documented, with African American patients experiencing higher mortality rates, compared with White Americans. This disparity is partly explained by differences in tumor biology, since triple-negative breast cancer (TNBC) is twice as common in African American patients. Troester et al. conducted RNA expression-based PAM-50 tumor subtyping to demonstrate significantly higher rates of biologically aggressive tumor subtypes among African Americans breast cancer patients, compared with white Americans.
Lisa Newman, MD, FACS 
Foregut
Teitelbaum EN et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2017 Jun 29. doi: 10.1007/s00464-017-5699-2 ; epub ahead of print.
This provides the longest follow-up to date regarding clinical efficacy of peroral endoscopic myotomy (POEM) in the United States. Although not a panacea, POEM appears to provide substantial durable clinical improvement in patients suffering from esophageal motility disorders.
Kevin Reavis, MD, FACS
Yufei Chen et al. Primary lymph node gastrinoma: A single institution experience. Surgery 2017 Nov;162(5):1088-94
This article retrospectively review a rare neuroendocrine (gastrinoma) tumor over a 25-year period at a single institution, noting all demographics and outcomes. Great update and refresher. The article then went farther, evaluating an even rarer occurrence of a primary lymph node gastrinoma within this patient population and followed those patients outcomes as well. Two “values” for the “price of one.”
Haisley KR et al. Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States. Am J Surg. 2017 Aug;214(2):299-302.
Gary Timmerman, MD, FACS
Recommended Reading lists are something of a tradition for ACS Surgery News. This feature has appeared several times over the years and it has always proved among the most popular items in the publication. But the project hinges on input from our Editorial Advisory Board, the members of which are already regularly called upon to help vet the publication’s content and give their advice. They have gone the extra mile and have once again chosen their “Best of 2017” studies in their own specialty areas, along with commentary on why their choices should be of interest to all surgeons. We hope our readers will find the list and the comments of interest.
General surgery
Cogbill TH et al. Rural general surgery: A 38-year experience with a regional network established by an integrated health system in the Midwestern United States. J Am Coll Surg. 2017;225(1):115-24.
This article is of particular interest because it provides details of an innovative, regional system of surgical care at the critical access hospitals and referral centers that cooperate seamlessly to improve quality of care and quality of practice for rural surgeons. It could serve as a model for similar independent hospitals and practices in a region to improve the practice lives of the surgeons in rural communities and preserve access to local care for rural patients.
Dimou FM et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: A propensity score analysis. J Am Coll Surg. 2017;224(4):502-14.This study is valuable because it sheds light on the current status of treatment of severe acute cholecystitis in the United States and reports outcomes of patients who get initial tube cholecystostomy. It demonstrates potential drawbacks of following the Tokyo Guidelines: fewer patients receiving definitive treatment (cholecystectomy) and higher mortality rates and readmissions.
Karen E. Deveney, MD, FACS
Palliative Care
Gani F et al. Palliative care utilization among patients admitted for gastrointestinal and thoracic cancers. J Palliat Med. 2017 Nov 3; doi: 10.1089/jpm.2017.0295; epub ahead of print.
Is this a matter of “too little too late”? This retrospective cross-sectional analysis of patients identified in the National Inpatient Sample database admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer determined that only 8.5% of patients admitted received palliative care services. Surgical patients were 79% less likely to have received a palliative care consultation, and then only after a prolonged length of stay or postoperative complication. Is referral to palliative care services hindered by its stigmatization with these outcomes?
Taylor LJ et al. A framework to improve surgeon communication in high-stakes surgical decisions: Best Case/Worst Case. JAMA Surgery. 2017;152(6):531-8.
My chief used to say, “You might not be teachable, but you are trainable!” After surgeons received training in the Best Case/Worst Case framework described in this paper, they demonstrated that it was possible to successfully change the focus of decision-making conversations from an isolated surgical problem – with its menu of technical solutions – instead into a discussion about treatment alternatives and outcomes. This intervention is a useful tool for one of the most invasive procedures of all – an exploration of a patient’s preferences and values that is necessary for shared decision making within the acute setting.
Makhani SS et al. Cognitive impairment and overall survival in frail surgical patients. J Amer Coll Surg. 2017 Nov;225(5):590-600.
In my preoperative discussions with families of frail patients, it is often quite evident that the factor driving their decision is the cognitive state of the patient and the consequences of its further decline, even when they are willing to accept the risks of physical frailty. This study in a large multidisciplinary cohort of patients undergoing major operations determined that a combined frailty (Fried frailty score) and cognitive assessment score (Emory Clock Draw Test) has a more powerful potential to predict adult patients at higher risk of overall survival than does either measurement alone. Dual frailty and cognitive screening appears to be a promising adjunct to the shared decision-making process.
Geoffrey P. Dunn, MD, FACS
Wilson DG et al. Patterns of care in hospitalized vascular patients at end of life. JAMA Surg. 2017;152(2):183-90.
This thoughtful study and the excellent accompanying invited commentary by William Schecter, MD, FACS, address a major, difficult issue that faces all physicians as our patients become older and sicker and our ability to keep them alive expands: How do we speak honestly with patients about their prognosis and likely outcomes and honor their autonomy in decision making?
Karen E. Deveney, MD, FACS
Practice Management
Robinson JR et al. Complexity of medical decision making in care provided by surgeons through patient portals. Surg Res. 2017;214:93-101.
This article describes an analysis of the content of patient portal messages exchanged between surgical providers and patients. The study demonstrates that more than 90% of these exchanges involved the delivery of medical care, and more than two-thirds of the messages contained medical decision making, which might have generated charges if done in a face-to-face outpatient encounter. The articles argues that surgeons are providing substantial medical care to their patients through patient portal message exchanges and suggests that models for compensation of this type of online care should be developed.
Gretchen Purcell Jackson, MD, FACS
Vascular Surgery
Bennett KM et al. Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg. 2017 Sep;66(3):794-801.
This article uses the ACS NSQIP database to assess outcomes of women undergoing intervention for carotid stenosis in a real-world setting and finds that major adverse cardiac events in the first 30 days is higher for carotid artery stenting (12.2%), compared with carotid endarterectomy (5.2%). What we need to keep in mind is that the practice of any intervention for asymptomatic carotid stenosis is being reevaluated in the new CREST study, which will compare current best medical management with carotid stenting and carotid endarterectomy. The indications are likely to change for all, but because women had less relative risk reduction in the early studies, we can expect that the benefits for intervention for women will continue to be less than those for men, calling to question when we should truly intervene, and how best to do so.
Gargiulo M et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg. 2017 Oct;66(4);1065-72.
This study found that endovascular aneurysm repair, performed in patients with large necks (greater than 28 mm), was associated with further neck enlargement at 2 years, and a higher risk of proximal type I endoleak, with the need for reintervention. This is one of many recent studies, all with similar findings. The issue becomes how we can best address larger infrarenal necks, whether by use of fenestrated grafts, snorkels/chimneys with extension of the seal zone, aptus, or other technologies. The question of whether all grafts have equal impacts on these more dilated necks has still to be elucidated. Nonetheless, when we stretch the instructions for use, there is an increased likelihood for more interventions.
Zettervall SL et al. Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. J Vasc Surg. 2017 Oct;66(4):1305.
This study found that endografts with suprarenal fixation were associated with a greater decline in renal function, compared with those with infrarenal fixation, as well as with a longer length of stay. The reasons for the renal function decline are not entirely clear, and there was a slight increase in contrast use for those with suprarenal fixation but were otherwise similar when comparing comorbidities. Clearly, assessment of any impact on long-term renal function is important, and may affect future choice of endografts.
Linda Harris, MD, FACS
Bariatric Surgery
Rosenthal RJ et al. Obesity in America. Surg Obes Relat Dis. 2017 Oct;13(10):1643-50.
Although much has been reported on the dramatic benefits of bariatric surgery, it remains a matter of deep disappointment that only 1%-2% of the eligible population is receiving this life-saving therapy. This is a paper that reports and analyzes the results of a national survey that was conducted on behalf of the American Society for Metabolic & Bariatric Surgery, in an attempt to identify barriers to access, public misconceptions on obesity and its consequences, and other pertinent factors. Survey results included the findings that, although 80% of Americans considered obesity as the most serious health risk problem, there was a clear overestimation of the effectiveness of diet and exercise alone. The importance of this paper lies in the persistent lack of recognition and/or awareness of proven, safe, and durable medical and surgical options in the lay population, highlighting the importance of aligning efforts and resources toward educating both the public and referring physicians.
Adams TD et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017 Sep 21;377(12):1143-55
This paper reports the results of an observational, prospective study that followed patients who received gastric bypass, in comparison with a group of patients who desired but did not receive gastric bypass, and a third group of obese patients who did not seek surgery. The authors concluded that gastric bypass provided durable, 12-year remission and prevention of such lethal diseases as diabetes, hypertension, and dyslipidemia. The importance of this study is in its detailed follow-up, the exceedingly high retention rate of 90% at 12 years, and the comparisons made between surgical and nonsurgical groups, demonstrating not only the benefits of gastric bypass, but as importantly, the hazards of not receiving this treatment.
Schauer PR et al. Bariatric surgery versus intensive medical therapy for diabetes – 5-year outcomes. N Engl J Med. 2017 Feb 16;376(7):641-51.This paper is the latest installment of the long-term results from the STAMPEDE trial conducted at the Cleveland Clinic. STAMPEDE is a randomized, controlled trial that compared the best, most “intensive” medical therapy for type 2 diabetes vs. bariatric surgery (comprising a mix of gastric bypass and sleeve gastrectomy). Prior publications from this group reported 1- and 3-year results, and this paper reported the 5-year results, demonstrating the persistent superiority of bariatric surgery over the most rigorous intensive medical therapy in the resolution or improvement of hyperglycemia in patients with BMI ranges of 27 kg/m2 to 43 kg/m2. Of further significance was the fact that there were no major late surgical complications except for one reoperation.
Samer Mattar, MD, FACS
Colon & Rectal Surgery
Jayne D et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: The ROLARR randomized clinical trial. JAMA. 2017;318(16):1569-80.
This trial of 471 rectal cancer patients demonstrated similar conversion rates for robotic (8.1%) and laparoscopic (12.2%) surgery. Of the other secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups.
Marshall JR et al. Laparoscopic lavage in the management of Hinchey grade III diverticulitis: A systematic review. Ann Surg. 2017;265(4):670-6.While there have been a number of groups using laparoscopic lavage in the setting of acute diverticulitis, including Hinchey grade III disease, several recent studies question this approach. This meta-analysis includes three recent randomized, controlled trials and analysis of 48 studies – demonstrating that rates of reintervention within 30 days to be 28.3% in the lavage group and 8.8% in the resection group. Other outcomes – including ICU admissions, 30- and 90-day mortality, or stoma rates at 12 months – were similar between groups.
Denost Q et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: The GRECCAR 5 randomized trial. Ann Surg. 2017;365(3):474-80.
While many studies have confirmed infectiveness of drainage after colectomy, there is still some controversy of the role of pelvic drainage after rectal surgery. A multicenter randomized, controlled trial with two parallel arms (drain vs. no drain) was conducted in 469 patients after rectal surgery for cancer. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Rates of pelvic sepsis were similar between drain and no drain: 16.1% vs. 18.0% (P = .58), and there was no difference in surgical morbidity, rate of reoperation, length of hospital stay, and rate of stoma closure between groups. Overall, this trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit.
Genevieve Melton-Meaux, MD, FACS
Breast Surgery
Giuliano AE et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 randomized clinical trial. JAMA. 2017 Sep 12;318(10):918-926.
Long-term outcomes from the practice-changing ACOSOG Z0011 (Alliance) trial confirming the safety of omitting completion axillary lymph node dissection in women with T1/T2 tumors treated by lumpectomy and whole-breast radiation when metastatic disease is identified in one or two sentinel nodes.
Masuda N et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017 Jun 1;376(22):2147-59.
Breast cancer patients that achieve a complete pathologic response after receiving neoadjuvant chemotherapy have a survival advantage, and patients found to have residual disease represent a higher-risk population subset. This prospective randomized clinical trial (known as the CREATE-X study) revealed that adjuvant capecitabine can significantly mitigate this risk, especially for patients with triple-negative breast cancer.
Curigliano G et al. De-escalating and escalating treatments for early stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol. 2017 Aug 1;28(8):1700-12.
This summary of the 2017 St. Gallen Conference proceedings provides a comprehensive yet concise review of contemporary standards of care in managing early stage breast cancer. Issues reviewed include lumpectomy margins, extent of breast/axillary surgery following neoadjuvant chemotherapy, options for breast radiation schedules following lumpectomy, and application of currently available gene expression profiles.
Troester MA et al. Racial differences in PAM50 subtypes in the Carolina Breast Cancer Study. J Natl Cancer Inst. 2018 Feb 1;110(2);doi: 10.1093/jnci/djx135; epub ahead of print (Aug 2017).
Breast cancer outcome disparities related to racial/ethnic identity are well documented, with African American patients experiencing higher mortality rates, compared with White Americans. This disparity is partly explained by differences in tumor biology, since triple-negative breast cancer (TNBC) is twice as common in African American patients. Troester et al. conducted RNA expression-based PAM-50 tumor subtyping to demonstrate significantly higher rates of biologically aggressive tumor subtypes among African Americans breast cancer patients, compared with white Americans.
Lisa Newman, MD, FACS
Foregut
Teitelbaum EN et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2017 Jun 29. doi: 10.1007/s00464-017-5699-2 ; epub ahead of print.
This provides the longest follow-up to date regarding clinical efficacy of peroral endoscopic myotomy (POEM) in the United States. Although not a panacea, POEM appears to provide substantial durable clinical improvement in patients suffering from esophageal motility disorders.
Kevin Reavis, MD, FACS
Yufei Chen et al. Primary lymph node gastrinoma: A single institution experience. Surgery 2017 Nov;162(5):1088-94
This article retrospectively review a rare neuroendocrine (gastrinoma) tumor over a 25-year period at a single institution, noting all demographics and outcomes. Great update and refresher. The article then went farther, evaluating an even rarer occurrence of a primary lymph node gastrinoma within this patient population and followed those patients outcomes as well. Two “values” for the “price of one.”
Haisley KR et al. Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States. Am J Surg. 2017 Aug;214(2):299-302.
Gary Timmerman, MD, FACS
Recommended Reading lists are something of a tradition for ACS Surgery News. This feature has appeared several times over the years and it has always proved among the most popular items in the publication. But the project hinges on input from our Editorial Advisory Board, the members of which are already regularly called upon to help vet the publication’s content and give their advice. They have gone the extra mile and have once again chosen their “Best of 2017” studies in their own specialty areas, along with commentary on why their choices should be of interest to all surgeons. We hope our readers will find the list and the comments of interest.
General surgery
Cogbill TH et al. Rural general surgery: A 38-year experience with a regional network established by an integrated health system in the Midwestern United States. J Am Coll Surg. 2017;225(1):115-24.
This article is of particular interest because it provides details of an innovative, regional system of surgical care at the critical access hospitals and referral centers that cooperate seamlessly to improve quality of care and quality of practice for rural surgeons. It could serve as a model for similar independent hospitals and practices in a region to improve the practice lives of the surgeons in rural communities and preserve access to local care for rural patients.
Dimou FM et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: A propensity score analysis. J Am Coll Surg. 2017;224(4):502-14.This study is valuable because it sheds light on the current status of treatment of severe acute cholecystitis in the United States and reports outcomes of patients who get initial tube cholecystostomy. It demonstrates potential drawbacks of following the Tokyo Guidelines: fewer patients receiving definitive treatment (cholecystectomy) and higher mortality rates and readmissions.
Karen E. Deveney, MD, FACS
Palliative Care
Gani F et al. Palliative care utilization among patients admitted for gastrointestinal and thoracic cancers. J Palliat Med. 2017 Nov 3; doi: 10.1089/jpm.2017.0295; epub ahead of print.
Is this a matter of “too little too late”? This retrospective cross-sectional analysis of patients identified in the National Inpatient Sample database admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer determined that only 8.5% of patients admitted received palliative care services. Surgical patients were 79% less likely to have received a palliative care consultation, and then only after a prolonged length of stay or postoperative complication. Is referral to palliative care services hindered by its stigmatization with these outcomes?
Taylor LJ et al. A framework to improve surgeon communication in high-stakes surgical decisions: Best Case/Worst Case. JAMA Surgery. 2017;152(6):531-8.
My chief used to say, “You might not be teachable, but you are trainable!” After surgeons received training in the Best Case/Worst Case framework described in this paper, they demonstrated that it was possible to successfully change the focus of decision-making conversations from an isolated surgical problem – with its menu of technical solutions – instead into a discussion about treatment alternatives and outcomes. This intervention is a useful tool for one of the most invasive procedures of all – an exploration of a patient’s preferences and values that is necessary for shared decision making within the acute setting.
Makhani SS et al. Cognitive impairment and overall survival in frail surgical patients. J Amer Coll Surg. 2017 Nov;225(5):590-600.
In my preoperative discussions with families of frail patients, it is often quite evident that the factor driving their decision is the cognitive state of the patient and the consequences of its further decline, even when they are willing to accept the risks of physical frailty. This study in a large multidisciplinary cohort of patients undergoing major operations determined that a combined frailty (Fried frailty score) and cognitive assessment score (Emory Clock Draw Test) has a more powerful potential to predict adult patients at higher risk of overall survival than does either measurement alone. Dual frailty and cognitive screening appears to be a promising adjunct to the shared decision-making process.
Geoffrey P. Dunn, MD, FACS
Wilson DG et al. Patterns of care in hospitalized vascular patients at end of life. JAMA Surg. 2017;152(2):183-90.
This thoughtful study and the excellent accompanying invited commentary by William Schecter, MD, FACS, address a major, difficult issue that faces all physicians as our patients become older and sicker and our ability to keep them alive expands: How do we speak honestly with patients about their prognosis and likely outcomes and honor their autonomy in decision making?
Karen E. Deveney, MD, FACS
Practice Management
Robinson JR et al. Complexity of medical decision making in care provided by surgeons through patient portals. Surg Res. 2017;214:93-101.
This article describes an analysis of the content of patient portal messages exchanged between surgical providers and patients. The study demonstrates that more than 90% of these exchanges involved the delivery of medical care, and more than two-thirds of the messages contained medical decision making, which might have generated charges if done in a face-to-face outpatient encounter. The articles argues that surgeons are providing substantial medical care to their patients through patient portal message exchanges and suggests that models for compensation of this type of online care should be developed.
Gretchen Purcell Jackson, MD, FACS
Vascular Surgery
Bennett KM et al. Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg. 2017 Sep;66(3):794-801.
This article uses the ACS NSQIP database to assess outcomes of women undergoing intervention for carotid stenosis in a real-world setting and finds that major adverse cardiac events in the first 30 days is higher for carotid artery stenting (12.2%), compared with carotid endarterectomy (5.2%). What we need to keep in mind is that the practice of any intervention for asymptomatic carotid stenosis is being reevaluated in the new CREST study, which will compare current best medical management with carotid stenting and carotid endarterectomy. The indications are likely to change for all, but because women had less relative risk reduction in the early studies, we can expect that the benefits for intervention for women will continue to be less than those for men, calling to question when we should truly intervene, and how best to do so.
Gargiulo M et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg. 2017 Oct;66(4);1065-72.
This study found that endovascular aneurysm repair, performed in patients with large necks (greater than 28 mm), was associated with further neck enlargement at 2 years, and a higher risk of proximal type I endoleak, with the need for reintervention. This is one of many recent studies, all with similar findings. The issue becomes how we can best address larger infrarenal necks, whether by use of fenestrated grafts, snorkels/chimneys with extension of the seal zone, aptus, or other technologies. The question of whether all grafts have equal impacts on these more dilated necks has still to be elucidated. Nonetheless, when we stretch the instructions for use, there is an increased likelihood for more interventions.
Zettervall SL et al. Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. J Vasc Surg. 2017 Oct;66(4):1305.
This study found that endografts with suprarenal fixation were associated with a greater decline in renal function, compared with those with infrarenal fixation, as well as with a longer length of stay. The reasons for the renal function decline are not entirely clear, and there was a slight increase in contrast use for those with suprarenal fixation but were otherwise similar when comparing comorbidities. Clearly, assessment of any impact on long-term renal function is important, and may affect future choice of endografts.
Linda Harris, MD, FACS
Bariatric Surgery
Rosenthal RJ et al. Obesity in America. Surg Obes Relat Dis. 2017 Oct;13(10):1643-50.
Although much has been reported on the dramatic benefits of bariatric surgery, it remains a matter of deep disappointment that only 1%-2% of the eligible population is receiving this life-saving therapy. This is a paper that reports and analyzes the results of a national survey that was conducted on behalf of the American Society for Metabolic & Bariatric Surgery, in an attempt to identify barriers to access, public misconceptions on obesity and its consequences, and other pertinent factors. Survey results included the findings that, although 80% of Americans considered obesity as the most serious health risk problem, there was a clear overestimation of the effectiveness of diet and exercise alone. The importance of this paper lies in the persistent lack of recognition and/or awareness of proven, safe, and durable medical and surgical options in the lay population, highlighting the importance of aligning efforts and resources toward educating both the public and referring physicians.
Adams TD et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017 Sep 21;377(12):1143-55
This paper reports the results of an observational, prospective study that followed patients who received gastric bypass, in comparison with a group of patients who desired but did not receive gastric bypass, and a third group of obese patients who did not seek surgery. The authors concluded that gastric bypass provided durable, 12-year remission and prevention of such lethal diseases as diabetes, hypertension, and dyslipidemia. The importance of this study is in its detailed follow-up, the exceedingly high retention rate of 90% at 12 years, and the comparisons made between surgical and nonsurgical groups, demonstrating not only the benefits of gastric bypass, but as importantly, the hazards of not receiving this treatment.
Schauer PR et al. Bariatric surgery versus intensive medical therapy for diabetes – 5-year outcomes. N Engl J Med. 2017 Feb 16;376(7):641-51.This paper is the latest installment of the long-term results from the STAMPEDE trial conducted at the Cleveland Clinic. STAMPEDE is a randomized, controlled trial that compared the best, most “intensive” medical therapy for type 2 diabetes vs. bariatric surgery (comprising a mix of gastric bypass and sleeve gastrectomy). Prior publications from this group reported 1- and 3-year results, and this paper reported the 5-year results, demonstrating the persistent superiority of bariatric surgery over the most rigorous intensive medical therapy in the resolution or improvement of hyperglycemia in patients with BMI ranges of 27 kg/m2 to 43 kg/m2. Of further significance was the fact that there were no major late surgical complications except for one reoperation.
Samer Mattar, MD, FACS
Colon & Rectal Surgery
Jayne D et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: The ROLARR randomized clinical trial. JAMA. 2017;318(16):1569-80.
This trial of 471 rectal cancer patients demonstrated similar conversion rates for robotic (8.1%) and laparoscopic (12.2%) surgery. Of the other secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups.
Marshall JR et al. Laparoscopic lavage in the management of Hinchey grade III diverticulitis: A systematic review. Ann Surg. 2017;265(4):670-6.While there have been a number of groups using laparoscopic lavage in the setting of acute diverticulitis, including Hinchey grade III disease, several recent studies question this approach. This meta-analysis includes three recent randomized, controlled trials and analysis of 48 studies – demonstrating that rates of reintervention within 30 days to be 28.3% in the lavage group and 8.8% in the resection group. Other outcomes – including ICU admissions, 30- and 90-day mortality, or stoma rates at 12 months – were similar between groups.
Denost Q et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: The GRECCAR 5 randomized trial. Ann Surg. 2017;365(3):474-80.
While many studies have confirmed infectiveness of drainage after colectomy, there is still some controversy of the role of pelvic drainage after rectal surgery. A multicenter randomized, controlled trial with two parallel arms (drain vs. no drain) was conducted in 469 patients after rectal surgery for cancer. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Rates of pelvic sepsis were similar between drain and no drain: 16.1% vs. 18.0% (P = .58), and there was no difference in surgical morbidity, rate of reoperation, length of hospital stay, and rate of stoma closure between groups. Overall, this trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit.
Genevieve Melton-Meaux, MD, FACS
Breast Surgery
Giuliano AE et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 randomized clinical trial. JAMA. 2017 Sep 12;318(10):918-926.
Long-term outcomes from the practice-changing ACOSOG Z0011 (Alliance) trial confirming the safety of omitting completion axillary lymph node dissection in women with T1/T2 tumors treated by lumpectomy and whole-breast radiation when metastatic disease is identified in one or two sentinel nodes.
Masuda N et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017 Jun 1;376(22):2147-59.
Breast cancer patients that achieve a complete pathologic response after receiving neoadjuvant chemotherapy have a survival advantage, and patients found to have residual disease represent a higher-risk population subset. This prospective randomized clinical trial (known as the CREATE-X study) revealed that adjuvant capecitabine can significantly mitigate this risk, especially for patients with triple-negative breast cancer.
Curigliano G et al. De-escalating and escalating treatments for early stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol. 2017 Aug 1;28(8):1700-12.
This summary of the 2017 St. Gallen Conference proceedings provides a comprehensive yet concise review of contemporary standards of care in managing early stage breast cancer. Issues reviewed include lumpectomy margins, extent of breast/axillary surgery following neoadjuvant chemotherapy, options for breast radiation schedules following lumpectomy, and application of currently available gene expression profiles.
Troester MA et al. Racial differences in PAM50 subtypes in the Carolina Breast Cancer Study. J Natl Cancer Inst. 2018 Feb 1;110(2);doi: 10.1093/jnci/djx135; epub ahead of print (Aug 2017).
Breast cancer outcome disparities related to racial/ethnic identity are well documented, with African American patients experiencing higher mortality rates, compared with White Americans. This disparity is partly explained by differences in tumor biology, since triple-negative breast cancer (TNBC) is twice as common in African American patients. Troester et al. conducted RNA expression-based PAM-50 tumor subtyping to demonstrate significantly higher rates of biologically aggressive tumor subtypes among African Americans breast cancer patients, compared with white Americans.
Lisa Newman, MD, FACS
Foregut
Teitelbaum EN et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2017 Jun 29. doi: 10.1007/s00464-017-5699-2 ; epub ahead of print.
This provides the longest follow-up to date regarding clinical efficacy of peroral endoscopic myotomy (POEM) in the United States. Although not a panacea, POEM appears to provide substantial durable clinical improvement in patients suffering from esophageal motility disorders.
Kevin Reavis, MD, FACS
Yufei Chen et al. Primary lymph node gastrinoma: A single institution experience. Surgery 2017 Nov;162(5):1088-94
This article retrospectively review a rare neuroendocrine (gastrinoma) tumor over a 25-year period at a single institution, noting all demographics and outcomes. Great update and refresher. The article then went farther, evaluating an even rarer occurrence of a primary lymph node gastrinoma within this patient population and followed those patients outcomes as well. Two “values” for the “price of one.”
Haisley KR et al. Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States. Am J Surg. 2017 Aug;214(2):299-302.
Gary Timmerman, MD, FACS
Clinical trial: Study underway of robot-assisted surgery for pelvic prolapse
Robotic Assisted Sacral Colpopexy: A Prospective Study Assessing Outcomes With Learning Curves is an open-label study that is being conducted on a new pelvic floor program for women with pelvic organ prolapse.
A prospective cohort of 100 patients will be recruited and the study will assess surgical time (total and specific essential portions), simulator training, and observed surgeon skills. Secondary endpoints include subjective outcomes for issues of sexual function and incontinence and adverse events such as genitourinary injury, blood loss, wound infection, and mesh erosion.
Kaiser Permanente is the trial sponsor, and patients aged 18-80 years who are undergoing robotic-assisted laparoscopic sacrocolpopexy with or without other procedures for pelvic organ prolapse are being recruited. For more details about the trial, visit https://goo.gl/pWq7qe.
SOURCE: ClinicalTrials.gov: NCT01535833.
Robotic Assisted Sacral Colpopexy: A Prospective Study Assessing Outcomes With Learning Curves is an open-label study that is being conducted on a new pelvic floor program for women with pelvic organ prolapse.
A prospective cohort of 100 patients will be recruited and the study will assess surgical time (total and specific essential portions), simulator training, and observed surgeon skills. Secondary endpoints include subjective outcomes for issues of sexual function and incontinence and adverse events such as genitourinary injury, blood loss, wound infection, and mesh erosion.
Kaiser Permanente is the trial sponsor, and patients aged 18-80 years who are undergoing robotic-assisted laparoscopic sacrocolpopexy with or without other procedures for pelvic organ prolapse are being recruited. For more details about the trial, visit https://goo.gl/pWq7qe.
SOURCE: ClinicalTrials.gov: NCT01535833.
Robotic Assisted Sacral Colpopexy: A Prospective Study Assessing Outcomes With Learning Curves is an open-label study that is being conducted on a new pelvic floor program for women with pelvic organ prolapse.
A prospective cohort of 100 patients will be recruited and the study will assess surgical time (total and specific essential portions), simulator training, and observed surgeon skills. Secondary endpoints include subjective outcomes for issues of sexual function and incontinence and adverse events such as genitourinary injury, blood loss, wound infection, and mesh erosion.
Kaiser Permanente is the trial sponsor, and patients aged 18-80 years who are undergoing robotic-assisted laparoscopic sacrocolpopexy with or without other procedures for pelvic organ prolapse are being recruited. For more details about the trial, visit https://goo.gl/pWq7qe.
SOURCE: ClinicalTrials.gov: NCT01535833.
SUMMARY FROM CLINICALTRIALS.GOV
VIDEO: Bariatric experts discuss recent experience with gastric balloon devices
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
VIDEO: MISS 2017– Hot topics, innovations, debates
Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.
Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.
Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.
VIDEO: ERAS for minimally invasive surgery
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
VIDEO: MBSAQIP data looks at sleeve gastrectomy outcomes
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ACS Clinical Congress: Don’t miss these sessions
The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.
Don’t miss these sessions
Acoustic gunshot sensor technology impacts trauma care.
Press Conference: TUESDAY, OCTOBER 24 - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)
~~~~
Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.
Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.
Location: 2, Upper Level of the San Diego Convention Center.
The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:
•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)
•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)
•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)
•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)
•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)
•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)
•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)
•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)
•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)
•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)
•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)
Social media
Follow Therese Borden on Twitter for live tweets during the meeting.
[email protected]
On Twitter @ThereseBorden
The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.
Don’t miss these sessions
Acoustic gunshot sensor technology impacts trauma care.
Press Conference: TUESDAY, OCTOBER 24 - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)
~~~~
Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.
Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.
Location: 2, Upper Level of the San Diego Convention Center.
The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:
•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)
•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)
•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)
•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)
•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)
•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)
•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)
•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)
•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)
•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)
•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)
Social media
Follow Therese Borden on Twitter for live tweets during the meeting.
[email protected]
On Twitter @ThereseBorden
The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.
Don’t miss these sessions
Acoustic gunshot sensor technology impacts trauma care.
Press Conference: TUESDAY, OCTOBER 24 - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)
~~~~
Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.
Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.
Location: 2, Upper Level of the San Diego Convention Center.
The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:
•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)
•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)
•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)
•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)
•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)
•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)
•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)
•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)
•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)
•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)
•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)
Social media
Follow Therese Borden on Twitter for live tweets during the meeting.
[email protected]
On Twitter @ThereseBorden
Clinical Trial Summary: Ergonomics of robotic surgery
The Ergonomics in Robotic Surgery clinical trial is being conducted to study the role of ergonomics in adjusting robotic surgery consoles to individual body types of operators. The study will look at comfort and physical support of gynecologic surgeons after performing a hysterectomy using a da Vinci robotic surgery console. One group of surgeons will adjust their own console and another group will have the console adjusted by an ergonomist.
For a further description of the study, go to www.clinicaltrials.gov.
[email protected]
On Twitter @ThereseBorden
The Ergonomics in Robotic Surgery clinical trial is being conducted to study the role of ergonomics in adjusting robotic surgery consoles to individual body types of operators. The study will look at comfort and physical support of gynecologic surgeons after performing a hysterectomy using a da Vinci robotic surgery console. One group of surgeons will adjust their own console and another group will have the console adjusted by an ergonomist.
For a further description of the study, go to www.clinicaltrials.gov.
[email protected]
On Twitter @ThereseBorden
The Ergonomics in Robotic Surgery clinical trial is being conducted to study the role of ergonomics in adjusting robotic surgery consoles to individual body types of operators. The study will look at comfort and physical support of gynecologic surgeons after performing a hysterectomy using a da Vinci robotic surgery console. One group of surgeons will adjust their own console and another group will have the console adjusted by an ergonomist.
For a further description of the study, go to www.clinicaltrials.gov.
[email protected]
On Twitter @ThereseBorden
FROM CLINICALTRIALS.GOV
Winds of change at the American Board of Surgery: An interview with Executive Director Jo Buyske, MD, FACS
Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.
Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.
We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.
Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?
Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.
SN: What has been the response from the Diplomates to the announcement?
Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.
SN: What happens now in this process of overhauling the recertification process?
Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.
Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.
Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.
The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.
The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?
Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.
We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?
Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.
It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?
Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.
SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.
SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.
Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.
Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.
We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.
Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?
Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.
SN: What has been the response from the Diplomates to the announcement?
Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.
SN: What happens now in this process of overhauling the recertification process?
Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.
Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.
Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.
The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.
The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?
Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.
We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?
Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.
It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?
Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.
SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.
SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.
Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.
Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.
We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.
Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?
Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.
SN: What has been the response from the Diplomates to the announcement?
Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.
SN: What happens now in this process of overhauling the recertification process?
Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.
Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.
Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.
The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.
The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?
Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.
We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?
Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.
It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?
Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.
SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.
SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.