General Thoracic

COLORADO SPRINGS – Patients with stage 1a non–small cell lung cancer deemed medically inoperable or high risk can undergo surgical resection safely and with excellent results, judging by results of a single-center retrospective study.

Indeed, their perioperative morbidity and mortality and 5-year recurrence-free survival rates were similar to those of low-risk patients undergoing tumor resection, Dr. Andrea S. Wolf said at the annual meeting of the Western Thoracic Surgical Association.

"These outcomes in high-risk patients provide the standard to which nonoperative therapies should be compared," said Dr. Wolf of Brigham and Women’s Hospital, Boston.

Of the 170,000 new cases of non–small cell lung cancer (NSCLC) diagnosed annually in the United States, 80% are deemed inoperable because of extensive malignancy or severe comorbidities, including chronic obstructive pulmonary disease, which affects roughly half of patients with NSCLC. Stereotactic body radiation therapy (SBRT), which uses advanced imaging techniques to deliver a targeted radiation dose to a tumor, is making substantial inroads in these inoperable patients. But Dr. Wolf’s study suggests that surgery is feasible for many patients considered high risk for pulmonary resection.

She reviewed the records of 66 patients with stage 1a disease considered high risk and 158 low-risk controls, all of whom underwent surgical resection at Brigham and Women’s Hospital during 1997-2006. None had pure bronchoalveolar carcinoma. Patients were deemed high risk if they were aged 80 years or older, or if their forced expiratory volume in 1 second (FEV₁) was 50% or less of the predicted amount. Forty percent of the high-risk patients met the age criterion, 60% met the diminished pulmonary function standard, and 5% fulfilled both. Pathologic findings were similar in the high- and low-risk groups, with a median tumor size of 1.5 cm.

With a median 6 years of follow-up, the local recurrence rate was 18% in the high-risk population and 16% in the low-risk cohort. The distant recurrence rate was 15% in both groups.

The 5-year overall survival rate was 54% in the high-risk group and significantly better at 68% in the low-risk group (P = .04). However, there was no significant difference in 5-year recurrence-free survival: 73% and 77% in the high- and low-risk groups, respectively.

Perioperative mortality occurred in 2% of low-risk patients and none of the high-risk patients. The perioperative major morbidity rate was 14% in the high-risk group and 8% in the low-risk group. Similarly, there were no significant between-group differences in the rates of any individual major complications, which included MI, pulmonary embolus, and reoperation for bleeding.

"Your rationale is right on target," discussant Dr. Joseph B. Shrager told Dr. Wolf. "It’s highly important in this era of SBRT to document the excellent results we can get with surgery in very-high-risk patients. And zero deaths, which is what you showed here and was equivalent to the experience with low-risk patients, is certainly admirable."

That being said, he added that he was disappointed with the Boston surgeons’ low use of anatomic resection in the high-risk group. Only 18% underwent lobectomy and another 6% received segmentectomy, while 76% had a wedge resection.

"There were less than one-tenth as many segmentectomies as wedges in the high-risk patients. So, really, what you’ve shown is that a lesser operation – or you might even say our least-good operation – can safely be done in high-risk patients. The question now is, is that lesser operation better than SBRT? Because if it’s not, then SBRT will probably win that argument. I have to say, I think we have a better chance of winning out over SBRT with surgery if we’re comparing it to segmentectomy than if we’re comparing it to wedge," said Dr. Shrager, professor and chief of the division of thoracic surgery at Stanford (Calif.) University.

Dr. Wolf replied that, like Dr. Shrager, she and her coinvestigators were "surprised" at the high rate of wedge resection because thoracic surgeons at Brigham and Women’s Hospital tend to promote anatomic resection whenever possible. She suspects some of the wedges were performed in an effort to spare parenchyma when a tumor bordered segmental boundaries.

Dr. Shrager also took the Boston surgeons to task for the fact that only 38% of high-risk patients in the series underwent lymph node sampling.

"Short of a proven survival advantage for surgery over SBRT, which we don’t have yet, all we can say is at least we’re providing better lymph node staging. So why not more lymph node sampling?" Dr. Shrager asked.

Dr. Wolf said this, too, came as a surprise to her and her colleagues. The most likely explanation is that in many instances patients and surgeons sought smaller, quicker operations in an effort to spare the patient. But given the compelling evidence showing that lymph node sampling is critical for accurate staging and for determining the need for adjunctive therapy, that’s not an adequate excuse.

"Going forward, we’re very interested in making sure nodes are sampled, even with wedge resections," she said.

Dr. Wolf declared no conflicts.☐

COLORADO SPRINGS – Patients with stage 1a non–small cell lung cancer deemed medically inoperable or high risk can undergo surgical resection safely and with excellent results, judging by results of a single-center retrospective study.

Indeed, their perioperative morbidity and mortality and 5-year recurrence-free survival rates were similar to those of low-risk patients undergoing tumor resection, Dr. Andrea S. Wolf said at the annual meeting of the Western Thoracic Surgical Association.

"These outcomes in high-risk patients provide the standard to which nonoperative therapies should be compared," said Dr. Wolf of Brigham and Women’s Hospital, Boston.

Of the 170,000 new cases of non–small cell lung cancer (NSCLC) diagnosed annually in the United States, 80% are deemed inoperable because of extensive malignancy or severe comorbidities, including chronic obstructive pulmonary disease, which affects roughly half of patients with NSCLC. Stereotactic body radiation therapy (SBRT), which uses advanced imaging techniques to deliver a targeted radiation dose to a tumor, is making substantial inroads in these inoperable patients. But Dr. Wolf’s study suggests that surgery is feasible for many patients considered high risk for pulmonary resection.

She reviewed the records of 66 patients with stage 1a disease considered high risk and 158 low-risk controls, all of whom underwent surgical resection at Brigham and Women’s Hospital during 1997-2006. None had pure bronchoalveolar carcinoma. Patients were deemed high risk if they were aged 80 years or older, or if their forced expiratory volume in 1 second (FEV₁) was 50% or less of the predicted amount. Forty percent of the high-risk patients met the age criterion, 60% met the diminished pulmonary function standard, and 5% fulfilled both. Pathologic findings were similar in the high- and low-risk groups, with a median tumor size of 1.5 cm.

With a median 6 years of follow-up, the local recurrence rate was 18% in the high-risk population and 16% in the low-risk cohort. The distant recurrence rate was 15% in both groups.

The 5-year overall survival rate was 54% in the high-risk group and significantly better at 68% in the low-risk group (P = .04). However, there was no significant difference in 5-year recurrence-free survival: 73% and 77% in the high- and low-risk groups, respectively.

Perioperative mortality occurred in 2% of low-risk patients and none of the high-risk patients. The perioperative major morbidity rate was 14% in the high-risk group and 8% in the low-risk group. Similarly, there were no significant between-group differences in the rates of any individual major complications, which included MI, pulmonary embolus, and reoperation for bleeding.

"Your rationale is right on target," discussant Dr. Joseph B. Shrager told Dr. Wolf. "It’s highly important in this era of SBRT to document the excellent results we can get with surgery in very-high-risk patients. And zero deaths, which is what you showed here and was equivalent to the experience with low-risk patients, is certainly admirable."

That being said, he added that he was disappointed with the Boston surgeons’ low use of anatomic resection in the high-risk group. Only 18% underwent lobectomy and another 6% received segmentectomy, while 76% had a wedge resection.

"There were less than one-tenth as many segmentectomies as wedges in the high-risk patients. So, really, what you’ve shown is that a lesser operation – or you might even say our least-good operation – can safely be done in high-risk patients. The question now is, is that lesser operation better than SBRT? Because if it’s not, then SBRT will probably win that argument. I have to say, I think we have a better chance of winning out over SBRT with surgery if we’re comparing it to segmentectomy than if we’re comparing it to wedge," said Dr. Shrager, professor and chief of the division of thoracic surgery at Stanford (Calif.) University.

Dr. Wolf replied that, like Dr. Shrager, she and her coinvestigators were "surprised" at the high rate of wedge resection because thoracic surgeons at Brigham and Women’s Hospital tend to promote anatomic resection whenever possible. She suspects some of the wedges were performed in an effort to spare parenchyma when a tumor bordered segmental boundaries.

Dr. Shrager also took the Boston surgeons to task for the fact that only 38% of high-risk patients in the series underwent lymph node sampling.

"Short of a proven survival advantage for surgery over SBRT, which we don’t have yet, all we can say is at least we’re providing better lymph node staging. So why not more lymph node sampling?" Dr. Shrager asked.

Dr. Wolf said this, too, came as a surprise to her and her colleagues. The most likely explanation is that in many instances patients and surgeons sought smaller, quicker operations in an effort to spare the patient. But given the compelling evidence showing that lymph node sampling is critical for accurate staging and for determining the need for adjunctive therapy, that’s not an adequate excuse.

"Going forward, we’re very interested in making sure nodes are sampled, even with wedge resections," she said.

Dr. Wolf declared no conflicts.☐

COLORADO SPRINGS – Patients with stage 1a non–small cell lung cancer deemed medically inoperable or high risk can undergo surgical resection safely and with excellent results, judging by results of a single-center retrospective study.

Indeed, their perioperative morbidity and mortality and 5-year recurrence-free survival rates were similar to those of low-risk patients undergoing tumor resection, Dr. Andrea S. Wolf said at the annual meeting of the Western Thoracic Surgical Association.

"These outcomes in high-risk patients provide the standard to which nonoperative therapies should be compared," said Dr. Wolf of Brigham and Women’s Hospital, Boston.

Of the 170,000 new cases of non–small cell lung cancer (NSCLC) diagnosed annually in the United States, 80% are deemed inoperable because of extensive malignancy or severe comorbidities, including chronic obstructive pulmonary disease, which affects roughly half of patients with NSCLC. Stereotactic body radiation therapy (SBRT), which uses advanced imaging techniques to deliver a targeted radiation dose to a tumor, is making substantial inroads in these inoperable patients. But Dr. Wolf’s study suggests that surgery is feasible for many patients considered high risk for pulmonary resection.

She reviewed the records of 66 patients with stage 1a disease considered high risk and 158 low-risk controls, all of whom underwent surgical resection at Brigham and Women’s Hospital during 1997-2006. None had pure bronchoalveolar carcinoma. Patients were deemed high risk if they were aged 80 years or older, or if their forced expiratory volume in 1 second (FEV₁) was 50% or less of the predicted amount. Forty percent of the high-risk patients met the age criterion, 60% met the diminished pulmonary function standard, and 5% fulfilled both. Pathologic findings were similar in the high- and low-risk groups, with a median tumor size of 1.5 cm.

With a median 6 years of follow-up, the local recurrence rate was 18% in the high-risk population and 16% in the low-risk cohort. The distant recurrence rate was 15% in both groups.

The 5-year overall survival rate was 54% in the high-risk group and significantly better at 68% in the low-risk group (P = .04). However, there was no significant difference in 5-year recurrence-free survival: 73% and 77% in the high- and low-risk groups, respectively.

Perioperative mortality occurred in 2% of low-risk patients and none of the high-risk patients. The perioperative major morbidity rate was 14% in the high-risk group and 8% in the low-risk group. Similarly, there were no significant between-group differences in the rates of any individual major complications, which included MI, pulmonary embolus, and reoperation for bleeding.

"Your rationale is right on target," discussant Dr. Joseph B. Shrager told Dr. Wolf. "It’s highly important in this era of SBRT to document the excellent results we can get with surgery in very-high-risk patients. And zero deaths, which is what you showed here and was equivalent to the experience with low-risk patients, is certainly admirable."

That being said, he added that he was disappointed with the Boston surgeons’ low use of anatomic resection in the high-risk group. Only 18% underwent lobectomy and another 6% received segmentectomy, while 76% had a wedge resection.

"There were less than one-tenth as many segmentectomies as wedges in the high-risk patients. So, really, what you’ve shown is that a lesser operation – or you might even say our least-good operation – can safely be done in high-risk patients. The question now is, is that lesser operation better than SBRT? Because if it’s not, then SBRT will probably win that argument. I have to say, I think we have a better chance of winning out over SBRT with surgery if we’re comparing it to segmentectomy than if we’re comparing it to wedge," said Dr. Shrager, professor and chief of the division of thoracic surgery at Stanford (Calif.) University.

Dr. Wolf replied that, like Dr. Shrager, she and her coinvestigators were "surprised" at the high rate of wedge resection because thoracic surgeons at Brigham and Women’s Hospital tend to promote anatomic resection whenever possible. She suspects some of the wedges were performed in an effort to spare parenchyma when a tumor bordered segmental boundaries.

Dr. Shrager also took the Boston surgeons to task for the fact that only 38% of high-risk patients in the series underwent lymph node sampling.

"Short of a proven survival advantage for surgery over SBRT, which we don’t have yet, all we can say is at least we’re providing better lymph node staging. So why not more lymph node sampling?" Dr. Shrager asked.

Dr. Wolf said this, too, came as a surprise to her and her colleagues. The most likely explanation is that in many instances patients and surgeons sought smaller, quicker operations in an effort to spare the patient. But given the compelling evidence showing that lymph node sampling is critical for accurate staging and for determining the need for adjunctive therapy, that’s not an adequate excuse.

"Going forward, we’re very interested in making sure nodes are sampled, even with wedge resections," she said.

Dr. Wolf declared no conflicts.☐

COLORADO SPRINGS – Improvements in pulmonary function tests and subjective complaints of breathlessness appear to be underappreciated benefits of the surgical repair of giant paraesophageal hernias.

Symptom assessment of these patients has generally focused on reflux and dysphagia, but these hernias also have adverse impacts on pulmonary function. Repair most benefits patients who are older, have bigger hernias, and worse baseline pulmonary function, said Dr. Philip W. Carrott Jr., of Virginia Mason Medical Center, Seattle.

"Patients with giant paraesophageal hernia and coexistent dyspnea or positional breathlessness should be reviewed by an experienced surgeon for elective repair, even when pulmonary comorbidities exist," Dr. Carrott concluded at the annual meeting of the Western Thoracic Surgical Association.

He based this advice on a single-center, retrospective, cohort study involving 120 patients who had pulmonary function tests preoperatively and again at a median of 106 days after surgery.

The overall group averaged 10% increases over baseline (P less than .001) in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), vital capacity, and volume-adjusted mid-expiratory flow (IsoFEF25-75), as well as a 2.9% increase in the diffusing capacity of the lung (DLCO).

The larger a patient’s hernia as expressed by percent intrathoracic stomach (ITS) on preoperative contrast studies, the greater the improvement in pulmonary function tests after surgery. Hernia size was the strongest predictor of improvement. For example, forced vital capacity improved by an average of 4.7%, compared with reference values in patients with the smallest hernias as expressed in a percent ITS of less than 50%, as compared with a 6.0% gain in patients with a preop 50%-74% ITS, a 9.1% improvement in those with 75%-99% ITS, and a 14.9% gain in FVC in patients with 100% ITS.

The postoperative improvement in lung function increased with each decade of patient age.

Patients with the worst preoperative lung function tended to have the biggest hernias – and the greatest objective and subjective improvements after surgery. For example, 36% of subjects had a reduced baseline FEV₁ not more than 75% of the reference value. Their vital capacity improved by 0.45 L, as compared with 0.23 L in patients without a reduced baseline FEV₁. And their DLCO improved by 1.23 mL CO/min/mm Hg, compared with just 0.23 in patients whose baseline FEV₁ was more than 75% of the reference value.

Of 63 patients who reported preoperative dyspnea, 47 (75%) noted subjective improvement in their respiratory function after hernia repair. Intriguingly, so did 30 of 57 patients (53%) not complaining of dyspnea at baseline.

Dr. Carrott and his fellow researchers postulate that restoring efficient diaphragmatic function is just part of the explanation. "The stomach probably has a paradoxical motion during respiration, such that the abdominal positive pressure is pushing against the negative effect of the lungs and chest wall," he said.

Study participants averaged 74 years of age, with a median of four preoperative symptoms. The most common were heartburn in 59%, early satiety in 54%, dyspnea in 52%, dysphagia in 47%, chest pain in 40%, and regurgitation in 39%.

Major comorbidities included pulmonary disease in 29% of subjects, heart disease in 35%, and obesity in 39%. An open Hill repair with no hiatal reinforcement was performed in 99% of patients, and 97% of the operations were elective.

Despite the substantial prevalence of comorbid conditions, there was no operative mortality. The mean length of stay was 4 days. One-third had complications, including six cases of arrhythmia, four instances of nausea delaying discharge, three cases of pneumonia, and two cases each of ileus, wound infection, or delirium.

Discussant Dr. Sean C. Grondin observed that paraesophageal hernia is a relatively common disease in the practice of most thoracic surgeons. And although the study provides some support for the notion that surgical repair may improve pulmonary function, its retrospective nature and only moderate size render it less than fully convincing.

"I think it still falls a little short just yet of providing conclusive evidence. At this time I would caution surgeons from telling patients that they’ll get a definitive improvement in their dyspnea after paraesophageal hernia repair, although it’s certainly a possibility," said Dr. Grondin of the University of Calgary (Alta).

Dr. Ross M. Bremner of St. Joseph’s Hospital and Medical Center, Phoenix, commented that: "I’ve long been telling my patients who have their entire stomach in the chest that they’re likely to get some improvement in their pulmonary function from repair. Now at least I have some data to show them they can get at least 10%-15% improvement."

Dr. Carrott reported that he had no disclosures.

COLORADO SPRINGS – Improvements in pulmonary function tests and subjective complaints of breathlessness appear to be underappreciated benefits of the surgical repair of giant paraesophageal hernias.

Symptom assessment of these patients has generally focused on reflux and dysphagia, but these hernias also have adverse impacts on pulmonary function. Repair most benefits patients who are older, have bigger hernias, and worse baseline pulmonary function, said Dr. Philip W. Carrott Jr., of Virginia Mason Medical Center, Seattle.

"Patients with giant paraesophageal hernia and coexistent dyspnea or positional breathlessness should be reviewed by an experienced surgeon for elective repair, even when pulmonary comorbidities exist," Dr. Carrott concluded at the annual meeting of the Western Thoracic Surgical Association.

He based this advice on a single-center, retrospective, cohort study involving 120 patients who had pulmonary function tests preoperatively and again at a median of 106 days after surgery.

The overall group averaged 10% increases over baseline (P less than .001) in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), vital capacity, and volume-adjusted mid-expiratory flow (IsoFEF25-75), as well as a 2.9% increase in the diffusing capacity of the lung (DLCO).

The larger a patient’s hernia as expressed by percent intrathoracic stomach (ITS) on preoperative contrast studies, the greater the improvement in pulmonary function tests after surgery. Hernia size was the strongest predictor of improvement. For example, forced vital capacity improved by an average of 4.7%, compared with reference values in patients with the smallest hernias as expressed in a percent ITS of less than 50%, as compared with a 6.0% gain in patients with a preop 50%-74% ITS, a 9.1% improvement in those with 75%-99% ITS, and a 14.9% gain in FVC in patients with 100% ITS.

The postoperative improvement in lung function increased with each decade of patient age.

Patients with the worst preoperative lung function tended to have the biggest hernias – and the greatest objective and subjective improvements after surgery. For example, 36% of subjects had a reduced baseline FEV₁ not more than 75% of the reference value. Their vital capacity improved by 0.45 L, as compared with 0.23 L in patients without a reduced baseline FEV₁. And their DLCO improved by 1.23 mL CO/min/mm Hg, compared with just 0.23 in patients whose baseline FEV₁ was more than 75% of the reference value.

Of 63 patients who reported preoperative dyspnea, 47 (75%) noted subjective improvement in their respiratory function after hernia repair. Intriguingly, so did 30 of 57 patients (53%) not complaining of dyspnea at baseline.

Dr. Carrott and his fellow researchers postulate that restoring efficient diaphragmatic function is just part of the explanation. "The stomach probably has a paradoxical motion during respiration, such that the abdominal positive pressure is pushing against the negative effect of the lungs and chest wall," he said.

Study participants averaged 74 years of age, with a median of four preoperative symptoms. The most common were heartburn in 59%, early satiety in 54%, dyspnea in 52%, dysphagia in 47%, chest pain in 40%, and regurgitation in 39%.

Major comorbidities included pulmonary disease in 29% of subjects, heart disease in 35%, and obesity in 39%. An open Hill repair with no hiatal reinforcement was performed in 99% of patients, and 97% of the operations were elective.

Despite the substantial prevalence of comorbid conditions, there was no operative mortality. The mean length of stay was 4 days. One-third had complications, including six cases of arrhythmia, four instances of nausea delaying discharge, three cases of pneumonia, and two cases each of ileus, wound infection, or delirium.

Discussant Dr. Sean C. Grondin observed that paraesophageal hernia is a relatively common disease in the practice of most thoracic surgeons. And although the study provides some support for the notion that surgical repair may improve pulmonary function, its retrospective nature and only moderate size render it less than fully convincing.

"I think it still falls a little short just yet of providing conclusive evidence. At this time I would caution surgeons from telling patients that they’ll get a definitive improvement in their dyspnea after paraesophageal hernia repair, although it’s certainly a possibility," said Dr. Grondin of the University of Calgary (Alta).

Dr. Ross M. Bremner of St. Joseph’s Hospital and Medical Center, Phoenix, commented that: "I’ve long been telling my patients who have their entire stomach in the chest that they’re likely to get some improvement in their pulmonary function from repair. Now at least I have some data to show them they can get at least 10%-15% improvement."

Dr. Carrott reported that he had no disclosures.

COLORADO SPRINGS – Improvements in pulmonary function tests and subjective complaints of breathlessness appear to be underappreciated benefits of the surgical repair of giant paraesophageal hernias.

Symptom assessment of these patients has generally focused on reflux and dysphagia, but these hernias also have adverse impacts on pulmonary function. Repair most benefits patients who are older, have bigger hernias, and worse baseline pulmonary function, said Dr. Philip W. Carrott Jr., of Virginia Mason Medical Center, Seattle.

"Patients with giant paraesophageal hernia and coexistent dyspnea or positional breathlessness should be reviewed by an experienced surgeon for elective repair, even when pulmonary comorbidities exist," Dr. Carrott concluded at the annual meeting of the Western Thoracic Surgical Association.

He based this advice on a single-center, retrospective, cohort study involving 120 patients who had pulmonary function tests preoperatively and again at a median of 106 days after surgery.

The overall group averaged 10% increases over baseline (P less than .001) in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), vital capacity, and volume-adjusted mid-expiratory flow (IsoFEF25-75), as well as a 2.9% increase in the diffusing capacity of the lung (DLCO).

The larger a patient’s hernia as expressed by percent intrathoracic stomach (ITS) on preoperative contrast studies, the greater the improvement in pulmonary function tests after surgery. Hernia size was the strongest predictor of improvement. For example, forced vital capacity improved by an average of 4.7%, compared with reference values in patients with the smallest hernias as expressed in a percent ITS of less than 50%, as compared with a 6.0% gain in patients with a preop 50%-74% ITS, a 9.1% improvement in those with 75%-99% ITS, and a 14.9% gain in FVC in patients with 100% ITS.

The postoperative improvement in lung function increased with each decade of patient age.

Patients with the worst preoperative lung function tended to have the biggest hernias – and the greatest objective and subjective improvements after surgery. For example, 36% of subjects had a reduced baseline FEV₁ not more than 75% of the reference value. Their vital capacity improved by 0.45 L, as compared with 0.23 L in patients without a reduced baseline FEV₁. And their DLCO improved by 1.23 mL CO/min/mm Hg, compared with just 0.23 in patients whose baseline FEV₁ was more than 75% of the reference value.

Of 63 patients who reported preoperative dyspnea, 47 (75%) noted subjective improvement in their respiratory function after hernia repair. Intriguingly, so did 30 of 57 patients (53%) not complaining of dyspnea at baseline.

Dr. Carrott and his fellow researchers postulate that restoring efficient diaphragmatic function is just part of the explanation. "The stomach probably has a paradoxical motion during respiration, such that the abdominal positive pressure is pushing against the negative effect of the lungs and chest wall," he said.

Study participants averaged 74 years of age, with a median of four preoperative symptoms. The most common were heartburn in 59%, early satiety in 54%, dyspnea in 52%, dysphagia in 47%, chest pain in 40%, and regurgitation in 39%.

Major comorbidities included pulmonary disease in 29% of subjects, heart disease in 35%, and obesity in 39%. An open Hill repair with no hiatal reinforcement was performed in 99% of patients, and 97% of the operations were elective.

Despite the substantial prevalence of comorbid conditions, there was no operative mortality. The mean length of stay was 4 days. One-third had complications, including six cases of arrhythmia, four instances of nausea delaying discharge, three cases of pneumonia, and two cases each of ileus, wound infection, or delirium.

Discussant Dr. Sean C. Grondin observed that paraesophageal hernia is a relatively common disease in the practice of most thoracic surgeons. And although the study provides some support for the notion that surgical repair may improve pulmonary function, its retrospective nature and only moderate size render it less than fully convincing.

"I think it still falls a little short just yet of providing conclusive evidence. At this time I would caution surgeons from telling patients that they’ll get a definitive improvement in their dyspnea after paraesophageal hernia repair, although it’s certainly a possibility," said Dr. Grondin of the University of Calgary (Alta).

Dr. Ross M. Bremner of St. Joseph’s Hospital and Medical Center, Phoenix, commented that: "I’ve long been telling my patients who have their entire stomach in the chest that they’re likely to get some improvement in their pulmonary function from repair. Now at least I have some data to show them they can get at least 10%-15% improvement."

Dr. Carrott reported that he had no disclosures.

PHILADELPHIA - Endobronchial ultrasound-guided biopsy of mediastinal lymph nodes in patients with operable non-small cell lung cancer worked as effectively for staging as did the standard approach - mediastinoscopy in a head-to-head comparison of the two methods.

"Our results have shown that EBUS-TBNA [endobronchial ultrasound-guided transbronchial needle aspiration], when performed as in this study, can replace mediastinoscopy for accurate staging of the mediastinum in potentially resectable lung cancer," Dr. Kazuhiro Yasufuku said at the annual meeting of the American Association for Thoracic Surgery.

Courtesy of Catherine Harrell/Elsevier.

Based on these results, which were obtained in 153 patients treated by any one of seven surgeons working at Toronto General Hospital, Dr. Yasufuku and his colleagues now routinely use EBUS-TBNA as their initial approach for staging patients with inoperable non?small cell lung cancer (NSCLC), who account for about 70% of all NSCLC patients they treat. As long as they can collect adequate cell specimens for cytologic analysis from the lymph node stations they routinely assess, they rely exclusively on EBUS-TBNA for staging, which allows them to avoid mediastinoscopy for most of their patients, Dr. Yasufuku said in an interview.

"We knew that EBUS-TBNA was good, but [until now] we never knew how it compared with the gold standard, mediastinoscopy," he said. The major limiting factor is lymph node size, he noted. Surgeons find it challenging to routinely obtain an adequate cell specimen from nodes smaller than 5 mm in diameter, Dr. Yasufuku said. "The smaller the node, the harder it is to put a needle into it."

The Toronto group uses rapid, onsite cytologic evaluation, which means that a cytologist attends the procedure in the combined surgical and endoscopy suite. In the study, and also in routine practice, "we can make repeated needle passes until we obtain good specimens. The surgeon can learn how to place the needle by getting immediate feedback" on the specimens, he said.

The specimens obtained allow for a tissue diagnosis, and typically provide enough material to assess cells for the presence of epidermal growth factor receptor mutations, he added.

EBUS-TBNA uses local rather than general anesthesia, is less invasive, and has fewer complications compared with mediastinoscopy, said Dr. Yasufuku, a thoracic surgeon and director of the interventional thoracic surgery program at Toronto General and the University of Toronto.

The study enrolled adults with NSCLC who required mediastinoscopy as part of their staging to determine their suitability for lung cancer resection. The study excluded patients who were not fit for definitive surgical resection, because the researchers used the status of the surgically excised lymph nodes as the basis for judging the diagnostic accuracy of both techniques.

During July 2006?August 2010, they enrolled 153 patients with an average age of 69 years. The most common NSCLC histologic subtype was adenocarcinoma (59%), followed by squamous cell carcinoma (25%). Staging by ultrasound imaging identified 57% of the patients with stage I or II disease, and 39% with stage IIIA disease. The remaining 4% had stage IIIB or stage IV disease.

All patients underwent general anesthesia. A surgeon first performed EBUS-TBNA on each patient, followed immediately by mediastinoscopy. All patients then underwent surgical lymph node resection to definitively assess their nodes if EBUS-TBNA, mediastinoscopy, or both did not show signs of metastatic disease.

The surgeons attempted biopsies at five lymph node stations in each patient: stations 2R, 2L, 4R, 4L, and 7. They successfully biopsied an average of three stations per patient using EBUS-TBNA, with an inadequate specimen obtained on an average of one station per patient. Average lymph node diameter on the short axis was 7 mm, and the procedure averaged a total of 20 minutes per patient. Overall, EBUS-TBNA identified 78 biopsies as malignant.

During mediastinoscopy, surgeons successfully biopsied an average of 3.8 nodes per patient, with inadequate specimens obtained from 10 nodes, an average of fewer than 0.1 inadequate specimen per patient.

Mediastinoscopy retrieved 79 biopsies that were identified as malignant.

Despite any sampling differences, the surgeons reached an identical and correct diagnosis using both modalities in 136 patients (89%). Neither modality produced the correct diagnosis in four patients (3%), which meant that overall EBUS-TBNA and mediastinoscopy agreed 92% of the time. EBUS-TBNA was correct and mediastinoscopy incorrect in seven patients, and mediastinoscopy was correct and EBUS-TBNA incorrect in six patients.

These outcomes meant that EBUS-TBNA had 81% sensitivity, 91% negative predictive value, and 93% diagnostic accuracy. Mediastinoscopy led to 79% sensitivity, 90% negative predictive value, and 93% accuracy. Both methods had a specificity and positive predictive value of 100%, Dr. Yasufuku said.

No complications occurred after EBUS-TBNA, but there were four minor complications following subsequent mediastinoscopy: Two patients had a hematoma, one had a recurrent nerve injury, and one had a wound infection.

"It was a very clean study, showing that in the hands of a trained surgeon in our setting, EBUS-TBNA works very well. We clearly showed that the diagnostic yield is similar, and that patients who require mediastinoscopy as part of their staging can undergo EBUS-TBNA as their initial modality. Depending on what you find, you want to also do mediastinoscopy," he added.

"I?m convinced that [Dr. Yasufuku has] demonstrated equivalent ability to stage the mediastinum with EBUS-TBNA and with mediastinoscopy," commented Dr. Joel D. Cooper, professor of surgery and chief of thoracic surgery at the University of Pennsylvania in Philadelphia.

The study was supported by Olympus Medical Systems, a company that markets an EBUS-TBNA system. Dr. Yasufuku said that he has received research support from Olympus. Dr. Cooper said that he had no relevant disclosures.

PHILADELPHIA - Endobronchial ultrasound-guided biopsy of mediastinal lymph nodes in patients with operable non-small cell lung cancer worked as effectively for staging as did the standard approach - mediastinoscopy in a head-to-head comparison of the two methods.

"Our results have shown that EBUS-TBNA [endobronchial ultrasound-guided transbronchial needle aspiration], when performed as in this study, can replace mediastinoscopy for accurate staging of the mediastinum in potentially resectable lung cancer," Dr. Kazuhiro Yasufuku said at the annual meeting of the American Association for Thoracic Surgery.

Courtesy of Catherine Harrell/Elsevier.

Based on these results, which were obtained in 153 patients treated by any one of seven surgeons working at Toronto General Hospital, Dr. Yasufuku and his colleagues now routinely use EBUS-TBNA as their initial approach for staging patients with inoperable non?small cell lung cancer (NSCLC), who account for about 70% of all NSCLC patients they treat. As long as they can collect adequate cell specimens for cytologic analysis from the lymph node stations they routinely assess, they rely exclusively on EBUS-TBNA for staging, which allows them to avoid mediastinoscopy for most of their patients, Dr. Yasufuku said in an interview.

"We knew that EBUS-TBNA was good, but [until now] we never knew how it compared with the gold standard, mediastinoscopy," he said. The major limiting factor is lymph node size, he noted. Surgeons find it challenging to routinely obtain an adequate cell specimen from nodes smaller than 5 mm in diameter, Dr. Yasufuku said. "The smaller the node, the harder it is to put a needle into it."

The Toronto group uses rapid, onsite cytologic evaluation, which means that a cytologist attends the procedure in the combined surgical and endoscopy suite. In the study, and also in routine practice, "we can make repeated needle passes until we obtain good specimens. The surgeon can learn how to place the needle by getting immediate feedback" on the specimens, he said.

The specimens obtained allow for a tissue diagnosis, and typically provide enough material to assess cells for the presence of epidermal growth factor receptor mutations, he added.

EBUS-TBNA uses local rather than general anesthesia, is less invasive, and has fewer complications compared with mediastinoscopy, said Dr. Yasufuku, a thoracic surgeon and director of the interventional thoracic surgery program at Toronto General and the University of Toronto.

The study enrolled adults with NSCLC who required mediastinoscopy as part of their staging to determine their suitability for lung cancer resection. The study excluded patients who were not fit for definitive surgical resection, because the researchers used the status of the surgically excised lymph nodes as the basis for judging the diagnostic accuracy of both techniques.

During July 2006?August 2010, they enrolled 153 patients with an average age of 69 years. The most common NSCLC histologic subtype was adenocarcinoma (59%), followed by squamous cell carcinoma (25%). Staging by ultrasound imaging identified 57% of the patients with stage I or II disease, and 39% with stage IIIA disease. The remaining 4% had stage IIIB or stage IV disease.

All patients underwent general anesthesia. A surgeon first performed EBUS-TBNA on each patient, followed immediately by mediastinoscopy. All patients then underwent surgical lymph node resection to definitively assess their nodes if EBUS-TBNA, mediastinoscopy, or both did not show signs of metastatic disease.

The surgeons attempted biopsies at five lymph node stations in each patient: stations 2R, 2L, 4R, 4L, and 7. They successfully biopsied an average of three stations per patient using EBUS-TBNA, with an inadequate specimen obtained on an average of one station per patient. Average lymph node diameter on the short axis was 7 mm, and the procedure averaged a total of 20 minutes per patient. Overall, EBUS-TBNA identified 78 biopsies as malignant.

During mediastinoscopy, surgeons successfully biopsied an average of 3.8 nodes per patient, with inadequate specimens obtained from 10 nodes, an average of fewer than 0.1 inadequate specimen per patient.

Mediastinoscopy retrieved 79 biopsies that were identified as malignant.

Despite any sampling differences, the surgeons reached an identical and correct diagnosis using both modalities in 136 patients (89%). Neither modality produced the correct diagnosis in four patients (3%), which meant that overall EBUS-TBNA and mediastinoscopy agreed 92% of the time. EBUS-TBNA was correct and mediastinoscopy incorrect in seven patients, and mediastinoscopy was correct and EBUS-TBNA incorrect in six patients.

These outcomes meant that EBUS-TBNA had 81% sensitivity, 91% negative predictive value, and 93% diagnostic accuracy. Mediastinoscopy led to 79% sensitivity, 90% negative predictive value, and 93% accuracy. Both methods had a specificity and positive predictive value of 100%, Dr. Yasufuku said.

No complications occurred after EBUS-TBNA, but there were four minor complications following subsequent mediastinoscopy: Two patients had a hematoma, one had a recurrent nerve injury, and one had a wound infection.

"It was a very clean study, showing that in the hands of a trained surgeon in our setting, EBUS-TBNA works very well. We clearly showed that the diagnostic yield is similar, and that patients who require mediastinoscopy as part of their staging can undergo EBUS-TBNA as their initial modality. Depending on what you find, you want to also do mediastinoscopy," he added.

"I?m convinced that [Dr. Yasufuku has] demonstrated equivalent ability to stage the mediastinum with EBUS-TBNA and with mediastinoscopy," commented Dr. Joel D. Cooper, professor of surgery and chief of thoracic surgery at the University of Pennsylvania in Philadelphia.

The study was supported by Olympus Medical Systems, a company that markets an EBUS-TBNA system. Dr. Yasufuku said that he has received research support from Olympus. Dr. Cooper said that he had no relevant disclosures.

PHILADELPHIA - Endobronchial ultrasound-guided biopsy of mediastinal lymph nodes in patients with operable non-small cell lung cancer worked as effectively for staging as did the standard approach - mediastinoscopy in a head-to-head comparison of the two methods.

"Our results have shown that EBUS-TBNA [endobronchial ultrasound-guided transbronchial needle aspiration], when performed as in this study, can replace mediastinoscopy for accurate staging of the mediastinum in potentially resectable lung cancer," Dr. Kazuhiro Yasufuku said at the annual meeting of the American Association for Thoracic Surgery.

Courtesy of Catherine Harrell/Elsevier.

Based on these results, which were obtained in 153 patients treated by any one of seven surgeons working at Toronto General Hospital, Dr. Yasufuku and his colleagues now routinely use EBUS-TBNA as their initial approach for staging patients with inoperable non?small cell lung cancer (NSCLC), who account for about 70% of all NSCLC patients they treat. As long as they can collect adequate cell specimens for cytologic analysis from the lymph node stations they routinely assess, they rely exclusively on EBUS-TBNA for staging, which allows them to avoid mediastinoscopy for most of their patients, Dr. Yasufuku said in an interview.

"We knew that EBUS-TBNA was good, but [until now] we never knew how it compared with the gold standard, mediastinoscopy," he said. The major limiting factor is lymph node size, he noted. Surgeons find it challenging to routinely obtain an adequate cell specimen from nodes smaller than 5 mm in diameter, Dr. Yasufuku said. "The smaller the node, the harder it is to put a needle into it."

The Toronto group uses rapid, onsite cytologic evaluation, which means that a cytologist attends the procedure in the combined surgical and endoscopy suite. In the study, and also in routine practice, "we can make repeated needle passes until we obtain good specimens. The surgeon can learn how to place the needle by getting immediate feedback" on the specimens, he said.

The specimens obtained allow for a tissue diagnosis, and typically provide enough material to assess cells for the presence of epidermal growth factor receptor mutations, he added.

EBUS-TBNA uses local rather than general anesthesia, is less invasive, and has fewer complications compared with mediastinoscopy, said Dr. Yasufuku, a thoracic surgeon and director of the interventional thoracic surgery program at Toronto General and the University of Toronto.

The study enrolled adults with NSCLC who required mediastinoscopy as part of their staging to determine their suitability for lung cancer resection. The study excluded patients who were not fit for definitive surgical resection, because the researchers used the status of the surgically excised lymph nodes as the basis for judging the diagnostic accuracy of both techniques.

During July 2006?August 2010, they enrolled 153 patients with an average age of 69 years. The most common NSCLC histologic subtype was adenocarcinoma (59%), followed by squamous cell carcinoma (25%). Staging by ultrasound imaging identified 57% of the patients with stage I or II disease, and 39% with stage IIIA disease. The remaining 4% had stage IIIB or stage IV disease.

All patients underwent general anesthesia. A surgeon first performed EBUS-TBNA on each patient, followed immediately by mediastinoscopy. All patients then underwent surgical lymph node resection to definitively assess their nodes if EBUS-TBNA, mediastinoscopy, or both did not show signs of metastatic disease.

The surgeons attempted biopsies at five lymph node stations in each patient: stations 2R, 2L, 4R, 4L, and 7. They successfully biopsied an average of three stations per patient using EBUS-TBNA, with an inadequate specimen obtained on an average of one station per patient. Average lymph node diameter on the short axis was 7 mm, and the procedure averaged a total of 20 minutes per patient. Overall, EBUS-TBNA identified 78 biopsies as malignant.

During mediastinoscopy, surgeons successfully biopsied an average of 3.8 nodes per patient, with inadequate specimens obtained from 10 nodes, an average of fewer than 0.1 inadequate specimen per patient.

Mediastinoscopy retrieved 79 biopsies that were identified as malignant.

Despite any sampling differences, the surgeons reached an identical and correct diagnosis using both modalities in 136 patients (89%). Neither modality produced the correct diagnosis in four patients (3%), which meant that overall EBUS-TBNA and mediastinoscopy agreed 92% of the time. EBUS-TBNA was correct and mediastinoscopy incorrect in seven patients, and mediastinoscopy was correct and EBUS-TBNA incorrect in six patients.

These outcomes meant that EBUS-TBNA had 81% sensitivity, 91% negative predictive value, and 93% diagnostic accuracy. Mediastinoscopy led to 79% sensitivity, 90% negative predictive value, and 93% accuracy. Both methods had a specificity and positive predictive value of 100%, Dr. Yasufuku said.

No complications occurred after EBUS-TBNA, but there were four minor complications following subsequent mediastinoscopy: Two patients had a hematoma, one had a recurrent nerve injury, and one had a wound infection.

"It was a very clean study, showing that in the hands of a trained surgeon in our setting, EBUS-TBNA works very well. We clearly showed that the diagnostic yield is similar, and that patients who require mediastinoscopy as part of their staging can undergo EBUS-TBNA as their initial modality. Depending on what you find, you want to also do mediastinoscopy," he added.

"I?m convinced that [Dr. Yasufuku has] demonstrated equivalent ability to stage the mediastinum with EBUS-TBNA and with mediastinoscopy," commented Dr. Joel D. Cooper, professor of surgery and chief of thoracic surgery at the University of Pennsylvania in Philadelphia.

The study was supported by Olympus Medical Systems, a company that markets an EBUS-TBNA system. Dr. Yasufuku said that he has received research support from Olympus. Dr. Cooper said that he had no relevant disclosures.

PHILADELPHIA – Current clinical practice is to repair symptomatic diaphragmatic hernias to avoid complications such as obstruction or gangrene. However, practice patterns are based largely on limited data from institutional case series, according to Dr. Subroto Paul and his colleagues at Cornell University in New York.

Mortality was significantly higher in those patients with uncomplicated hernia who went on to readmission with obstruction or gangrene, Dr. Paul said at the annual meeting of the American Association for Thoracic Surgery, where he presented an analysis of the National Inpatient Sample (NIS) database.

Over a 10-year period, 193,554 patient admissions were identified for the primary diagnosis of diaphragmatic hernia of any type. An uncomplicated diaphragmatic hernia was the diagnosis in 161,777 (83.6%) admissions. Of these, 38,764 (24.0%) patients underwent an elective repair of their hernia as the principal procedure for their admission.

A diagnosis of diaphragmatic hernia with obstruction or gangrene was the reason for admission in 31,127 (16.1%) and 651 (0.3%) patients, respectively. Mortality was significantly higher in patients who were admitted with obstruction or gangrene (4.5% vs. 27.5%, respectively), compared with patients who were admitted for an elective hernia repair (1%).

Morbidity from pneumonia and sepsis was also significantly higher in patients who were admitted for obstruction or gangrene.

Symptomatic admission was associated with more intensive hospitalization, as evidenced by significantly increasing length of stay – 6 days (uncomplicated) vs. 9 days (obstruction) vs. 17.5 days (gangrene) – and the need for mechanical ventilation (3.6% vs. 9.7 vs. 41.3%, respectively).

Based on their mortality data, the authors also performed a lifetime risk analysis that suggested that elective repair is associated with a favorable risk-benefit profile for patients in their 50s, 60s, and perhaps early 70s.

"In this large national database study, the prevalence of diaphragmatic hernia per hospital admission is 1:2,000. Admissions resulting from gangrene or obstruction are not uncommon and are associated with worse outcomes than [is repair] in uncomplicated hernias.

"This analysis suggests the practice of repair of uncomplicated diaphragmatic hernia may avoid the morbidity and mortality associated with either obstruction or gangrene," he concluded.

Dr. Paul reported that he had no relevant disclosures. ☐

PHILADELPHIA – Current clinical practice is to repair symptomatic diaphragmatic hernias to avoid complications such as obstruction or gangrene. However, practice patterns are based largely on limited data from institutional case series, according to Dr. Subroto Paul and his colleagues at Cornell University in New York.

Mortality was significantly higher in those patients with uncomplicated hernia who went on to readmission with obstruction or gangrene, Dr. Paul said at the annual meeting of the American Association for Thoracic Surgery, where he presented an analysis of the National Inpatient Sample (NIS) database.

Over a 10-year period, 193,554 patient admissions were identified for the primary diagnosis of diaphragmatic hernia of any type. An uncomplicated diaphragmatic hernia was the diagnosis in 161,777 (83.6%) admissions. Of these, 38,764 (24.0%) patients underwent an elective repair of their hernia as the principal procedure for their admission.

A diagnosis of diaphragmatic hernia with obstruction or gangrene was the reason for admission in 31,127 (16.1%) and 651 (0.3%) patients, respectively. Mortality was significantly higher in patients who were admitted with obstruction or gangrene (4.5% vs. 27.5%, respectively), compared with patients who were admitted for an elective hernia repair (1%).

Morbidity from pneumonia and sepsis was also significantly higher in patients who were admitted for obstruction or gangrene.

Symptomatic admission was associated with more intensive hospitalization, as evidenced by significantly increasing length of stay – 6 days (uncomplicated) vs. 9 days (obstruction) vs. 17.5 days (gangrene) – and the need for mechanical ventilation (3.6% vs. 9.7 vs. 41.3%, respectively).

Based on their mortality data, the authors also performed a lifetime risk analysis that suggested that elective repair is associated with a favorable risk-benefit profile for patients in their 50s, 60s, and perhaps early 70s.

"In this large national database study, the prevalence of diaphragmatic hernia per hospital admission is 1:2,000. Admissions resulting from gangrene or obstruction are not uncommon and are associated with worse outcomes than [is repair] in uncomplicated hernias.

"This analysis suggests the practice of repair of uncomplicated diaphragmatic hernia may avoid the morbidity and mortality associated with either obstruction or gangrene," he concluded.

Dr. Paul reported that he had no relevant disclosures. ☐

PHILADELPHIA – Current clinical practice is to repair symptomatic diaphragmatic hernias to avoid complications such as obstruction or gangrene. However, practice patterns are based largely on limited data from institutional case series, according to Dr. Subroto Paul and his colleagues at Cornell University in New York.

Mortality was significantly higher in those patients with uncomplicated hernia who went on to readmission with obstruction or gangrene, Dr. Paul said at the annual meeting of the American Association for Thoracic Surgery, where he presented an analysis of the National Inpatient Sample (NIS) database.

Over a 10-year period, 193,554 patient admissions were identified for the primary diagnosis of diaphragmatic hernia of any type. An uncomplicated diaphragmatic hernia was the diagnosis in 161,777 (83.6%) admissions. Of these, 38,764 (24.0%) patients underwent an elective repair of their hernia as the principal procedure for their admission.

A diagnosis of diaphragmatic hernia with obstruction or gangrene was the reason for admission in 31,127 (16.1%) and 651 (0.3%) patients, respectively. Mortality was significantly higher in patients who were admitted with obstruction or gangrene (4.5% vs. 27.5%, respectively), compared with patients who were admitted for an elective hernia repair (1%).

Morbidity from pneumonia and sepsis was also significantly higher in patients who were admitted for obstruction or gangrene.

Symptomatic admission was associated with more intensive hospitalization, as evidenced by significantly increasing length of stay – 6 days (uncomplicated) vs. 9 days (obstruction) vs. 17.5 days (gangrene) – and the need for mechanical ventilation (3.6% vs. 9.7 vs. 41.3%, respectively).

Based on their mortality data, the authors also performed a lifetime risk analysis that suggested that elective repair is associated with a favorable risk-benefit profile for patients in their 50s, 60s, and perhaps early 70s.

"In this large national database study, the prevalence of diaphragmatic hernia per hospital admission is 1:2,000. Admissions resulting from gangrene or obstruction are not uncommon and are associated with worse outcomes than [is repair] in uncomplicated hernias.

"This analysis suggests the practice of repair of uncomplicated diaphragmatic hernia may avoid the morbidity and mortality associated with either obstruction or gangrene," he concluded.

Dr. Paul reported that he had no relevant disclosures. ☐

BOCA RATON, FLA. – Adherence to Surgical Care Improvement Program measures that are aimed at preventing surgical site infections has not had the desired effect, according to a large national Veterans Affairs study.

There is widespread agreement that reducing surgical site infections is a worthy quality improvement goal. These infections are associated with a twofold increase in mortality, a 60% increase in ICU admission, and a fivefold greater likelihood of hospital readmission after discharge.

But the VA study results showing that the SCIP hasn’t reduced surgical site infection rates call into question whether the program is worth continuing.

"SCIP adherence is not informative to third-party payers, administrators, or patients. The policy of continued SCIP measurement for public reporting and payment should be reevaluated," Dr. Mary T. Hawn declared in presenting the VA study findings at the annual meeting of the American Surgical Association.

SCIP is a multiyear partnership that was initiated in 2003 with the goal of reducing surgical morbidity and mortality at U.S. hospitals. Among the 10 national organizations that are represented on the SCIP steering committee are the American College of Surgeons, the American Hospital Association, the U.S. Department of Veterans Affairs, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Joint Commission.

Dr. Hawn presented a retrospective study of 60,853 procedures performed at 112 VA hospitals during 2005-2009. The outcome measure was the combined rate of superficial and deep surgical site infections (SSIs) occurring within 30 days of surgery.

The independent variables were adherence to each of five SCIP surgical site infection prevention measures that hospitals are required to collect and report. The five measures are timely administration of a prophylactic antibiotic, timely discontinuation of the antibiotic, appropriate antibiotic coverage, hair removal, and normothermia for colon procedures.

In addition, investigators tracked the impact of rates of adherence to all five measures in a given case, a combined metric they called composite SCIP.

This was the first study to use individual patient-level data for evaluating SCIP. Investigators were able to adjust for the presence of comorbid conditions that are known to affect the risk of SSIs, such as diabetes, dyspnea, and corticosteroid use, noted Dr. Hawn of the University of Alabama at Birmingham.

The overall SSI rate was 6.2%. It didn’t vary significantly over the 5-year study period, which began when the SCIP measures were first implemented in the VA system. Rates of adherence to the five SCIP measures quickly climbed to high levels during the first 6 months, probably because of the VA’s pay-for-performance incentives, she explained.

A first look at the data suggested that SCIP might be performing as intended. For example, there was an 81% adherence rate to the composite SCIP measure, and surgical cases meeting that standard had a 45% lower SSI rate than did those in which all five measures weren’t met. However, when patient-level SSI risk factors were introduced in a multivariate logistic regression analysis, there was no longer any association between SCIP adherence and SSI rates.

SCIP adherence rates ranged from a high of 86.4% for orthopedic surgery to a low of 60.4% for colorectal procedures. Adherence rates for gynecologic and vascular procedures were 85.9% and 81.6%, respectively.

In a separate analysis, Dr. Hawn and her colleagues looked at the relationship between a hospital’s adherence to SCIP measures and the institutional SSI rate. Once again, they found that there was none. The difference in hospital rates of SCIP adherence accounted for a mere 2% of the variation in hospital-wide SSI rates.

Dr. Hawn said that it is particularly troubling, in light of the VA data, to consider that public reporting of the SCIP adherence rates is being used to guide patients to what are supposed to be high-quality hospitals. "Are we really guiding patients to the right hospitals?" she asked.

Discussant Dr. David B. Hoyt noted that the collection of SCIP data constitutes a huge cost for American hospitals.

"It’s essential that quality measurement systems put in place actually correlate with improvement in quality. This study today is a critical example of how a well-intended process can in fact fail to reduce surgical infections. Overall, the SCIP program does not achieve its goal," said Dr. Hoyt, executive director of the American College of Surgeons.

"The data collection burden has increased in the last several years, and unless indicators that are ineffective are dropped, the expense of adding new indicators cannot be accommodated," he added.

Dr. Donald E. Fry commented that the SCIP measures are valid. The trouble is, they’re not inclusive.

"To paraphrase Paul Simon, ‘There must be 50 ways to get an SSI.’ And antibiotics are only a small portion of that," said Dr. Fry, executive vice president at Michael Pine and Associates, Chicago, an analytic health care consulting firm.

"I hope that this presentation will be a significant stimulus for us to go forward with not measuring silly process measures. This is not synchronized swimming. We need to be measuring outcomes. We need objective measures of what it is we’re trying to do, looking at how good hospitals do it well and bad ones don’t do it so well, and coming up with an entire strategy for SSIs," he said.

The SCIP study was funded by the VA. Dr. Hawn declared having no relevant financial interests. ☐

BOCA RATON, FLA. – Adherence to Surgical Care Improvement Program measures that are aimed at preventing surgical site infections has not had the desired effect, according to a large national Veterans Affairs study.

There is widespread agreement that reducing surgical site infections is a worthy quality improvement goal. These infections are associated with a twofold increase in mortality, a 60% increase in ICU admission, and a fivefold greater likelihood of hospital readmission after discharge.

But the VA study results showing that the SCIP hasn’t reduced surgical site infection rates call into question whether the program is worth continuing.

"SCIP adherence is not informative to third-party payers, administrators, or patients. The policy of continued SCIP measurement for public reporting and payment should be reevaluated," Dr. Mary T. Hawn declared in presenting the VA study findings at the annual meeting of the American Surgical Association.

SCIP is a multiyear partnership that was initiated in 2003 with the goal of reducing surgical morbidity and mortality at U.S. hospitals. Among the 10 national organizations that are represented on the SCIP steering committee are the American College of Surgeons, the American Hospital Association, the U.S. Department of Veterans Affairs, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Joint Commission.

Dr. Hawn presented a retrospective study of 60,853 procedures performed at 112 VA hospitals during 2005-2009. The outcome measure was the combined rate of superficial and deep surgical site infections (SSIs) occurring within 30 days of surgery.

The independent variables were adherence to each of five SCIP surgical site infection prevention measures that hospitals are required to collect and report. The five measures are timely administration of a prophylactic antibiotic, timely discontinuation of the antibiotic, appropriate antibiotic coverage, hair removal, and normothermia for colon procedures.

In addition, investigators tracked the impact of rates of adherence to all five measures in a given case, a combined metric they called composite SCIP.

This was the first study to use individual patient-level data for evaluating SCIP. Investigators were able to adjust for the presence of comorbid conditions that are known to affect the risk of SSIs, such as diabetes, dyspnea, and corticosteroid use, noted Dr. Hawn of the University of Alabama at Birmingham.

The overall SSI rate was 6.2%. It didn’t vary significantly over the 5-year study period, which began when the SCIP measures were first implemented in the VA system. Rates of adherence to the five SCIP measures quickly climbed to high levels during the first 6 months, probably because of the VA’s pay-for-performance incentives, she explained.

A first look at the data suggested that SCIP might be performing as intended. For example, there was an 81% adherence rate to the composite SCIP measure, and surgical cases meeting that standard had a 45% lower SSI rate than did those in which all five measures weren’t met. However, when patient-level SSI risk factors were introduced in a multivariate logistic regression analysis, there was no longer any association between SCIP adherence and SSI rates.

SCIP adherence rates ranged from a high of 86.4% for orthopedic surgery to a low of 60.4% for colorectal procedures. Adherence rates for gynecologic and vascular procedures were 85.9% and 81.6%, respectively.

In a separate analysis, Dr. Hawn and her colleagues looked at the relationship between a hospital’s adherence to SCIP measures and the institutional SSI rate. Once again, they found that there was none. The difference in hospital rates of SCIP adherence accounted for a mere 2% of the variation in hospital-wide SSI rates.

Dr. Hawn said that it is particularly troubling, in light of the VA data, to consider that public reporting of the SCIP adherence rates is being used to guide patients to what are supposed to be high-quality hospitals. "Are we really guiding patients to the right hospitals?" she asked.

Discussant Dr. David B. Hoyt noted that the collection of SCIP data constitutes a huge cost for American hospitals.

"It’s essential that quality measurement systems put in place actually correlate with improvement in quality. This study today is a critical example of how a well-intended process can in fact fail to reduce surgical infections. Overall, the SCIP program does not achieve its goal," said Dr. Hoyt, executive director of the American College of Surgeons.

"The data collection burden has increased in the last several years, and unless indicators that are ineffective are dropped, the expense of adding new indicators cannot be accommodated," he added.

Dr. Donald E. Fry commented that the SCIP measures are valid. The trouble is, they’re not inclusive.

"To paraphrase Paul Simon, ‘There must be 50 ways to get an SSI.’ And antibiotics are only a small portion of that," said Dr. Fry, executive vice president at Michael Pine and Associates, Chicago, an analytic health care consulting firm.

"I hope that this presentation will be a significant stimulus for us to go forward with not measuring silly process measures. This is not synchronized swimming. We need to be measuring outcomes. We need objective measures of what it is we’re trying to do, looking at how good hospitals do it well and bad ones don’t do it so well, and coming up with an entire strategy for SSIs," he said.

The SCIP study was funded by the VA. Dr. Hawn declared having no relevant financial interests. ☐

BOCA RATON, FLA. – Adherence to Surgical Care Improvement Program measures that are aimed at preventing surgical site infections has not had the desired effect, according to a large national Veterans Affairs study.

There is widespread agreement that reducing surgical site infections is a worthy quality improvement goal. These infections are associated with a twofold increase in mortality, a 60% increase in ICU admission, and a fivefold greater likelihood of hospital readmission after discharge.

But the VA study results showing that the SCIP hasn’t reduced surgical site infection rates call into question whether the program is worth continuing.

"SCIP adherence is not informative to third-party payers, administrators, or patients. The policy of continued SCIP measurement for public reporting and payment should be reevaluated," Dr. Mary T. Hawn declared in presenting the VA study findings at the annual meeting of the American Surgical Association.

SCIP is a multiyear partnership that was initiated in 2003 with the goal of reducing surgical morbidity and mortality at U.S. hospitals. Among the 10 national organizations that are represented on the SCIP steering committee are the American College of Surgeons, the American Hospital Association, the U.S. Department of Veterans Affairs, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Joint Commission.

Dr. Hawn presented a retrospective study of 60,853 procedures performed at 112 VA hospitals during 2005-2009. The outcome measure was the combined rate of superficial and deep surgical site infections (SSIs) occurring within 30 days of surgery.

The independent variables were adherence to each of five SCIP surgical site infection prevention measures that hospitals are required to collect and report. The five measures are timely administration of a prophylactic antibiotic, timely discontinuation of the antibiotic, appropriate antibiotic coverage, hair removal, and normothermia for colon procedures.

In addition, investigators tracked the impact of rates of adherence to all five measures in a given case, a combined metric they called composite SCIP.

This was the first study to use individual patient-level data for evaluating SCIP. Investigators were able to adjust for the presence of comorbid conditions that are known to affect the risk of SSIs, such as diabetes, dyspnea, and corticosteroid use, noted Dr. Hawn of the University of Alabama at Birmingham.

The overall SSI rate was 6.2%. It didn’t vary significantly over the 5-year study period, which began when the SCIP measures were first implemented in the VA system. Rates of adherence to the five SCIP measures quickly climbed to high levels during the first 6 months, probably because of the VA’s pay-for-performance incentives, she explained.

A first look at the data suggested that SCIP might be performing as intended. For example, there was an 81% adherence rate to the composite SCIP measure, and surgical cases meeting that standard had a 45% lower SSI rate than did those in which all five measures weren’t met. However, when patient-level SSI risk factors were introduced in a multivariate logistic regression analysis, there was no longer any association between SCIP adherence and SSI rates.

SCIP adherence rates ranged from a high of 86.4% for orthopedic surgery to a low of 60.4% for colorectal procedures. Adherence rates for gynecologic and vascular procedures were 85.9% and 81.6%, respectively.

In a separate analysis, Dr. Hawn and her colleagues looked at the relationship between a hospital’s adherence to SCIP measures and the institutional SSI rate. Once again, they found that there was none. The difference in hospital rates of SCIP adherence accounted for a mere 2% of the variation in hospital-wide SSI rates.

Dr. Hawn said that it is particularly troubling, in light of the VA data, to consider that public reporting of the SCIP adherence rates is being used to guide patients to what are supposed to be high-quality hospitals. "Are we really guiding patients to the right hospitals?" she asked.

Discussant Dr. David B. Hoyt noted that the collection of SCIP data constitutes a huge cost for American hospitals.

"It’s essential that quality measurement systems put in place actually correlate with improvement in quality. This study today is a critical example of how a well-intended process can in fact fail to reduce surgical infections. Overall, the SCIP program does not achieve its goal," said Dr. Hoyt, executive director of the American College of Surgeons.

"The data collection burden has increased in the last several years, and unless indicators that are ineffective are dropped, the expense of adding new indicators cannot be accommodated," he added.

Dr. Donald E. Fry commented that the SCIP measures are valid. The trouble is, they’re not inclusive.

"To paraphrase Paul Simon, ‘There must be 50 ways to get an SSI.’ And antibiotics are only a small portion of that," said Dr. Fry, executive vice president at Michael Pine and Associates, Chicago, an analytic health care consulting firm.

"I hope that this presentation will be a significant stimulus for us to go forward with not measuring silly process measures. This is not synchronized swimming. We need to be measuring outcomes. We need objective measures of what it is we’re trying to do, looking at how good hospitals do it well and bad ones don’t do it so well, and coming up with an entire strategy for SSIs," he said.

The SCIP study was funded by the VA. Dr. Hawn declared having no relevant financial interests. ☐

BOCA RATON, FLA. — Minimally invasive esophagectomy has advanced to the point where it offers significant advantages over open esophagectomy in terms of operative morbidity and mortality, judging by results of a single-center review of 980 cases.

Published series indicate that the operative mortality of open esophagectomy is 8%-21%, although a few high-volume medical centers have reported rates as low as 3%.

"There is a perception among patients and physicians that open esophagectomy is to be avoided at all costs because of it substantial morbidity," Dr. James D. Luketich said at the annual meeting of the American Surgical Association.

In his review of 980 consecutive, elective, nonurgent, minimally invasive esophagectomies, the 30-day mortality was just 1.8%. Median operative time was 6.7 hours, which dropped to 4 hours in cases that were not done by residents. The median ICU stay was 2.0 days, with a median hospital length of stay of 8 days. A median 21 lymph nodes were dissected, and 98% of cases had negative surgical margins.

"A less invasive surgical approach for esophageal cancer would improve the standard of care by reducing morbidity and shortening hospital stays and time to return to daily activities. If successful, surgeons might see more early-stage referrals from Barrett’s patients now in surveillance," added Dr. Luketich, professor of surgery and chief of the Heart, Lung and Esophageal Surgery Institute at the University of Pittsburgh Medical Center.

Using a modified Ivor-Lewis approach involving laparoscopic conduit preparation, videothoracoscopic esophageal mobilization, and an intrathoracic anastomosis is preferable to the McKeown approach when the minimally invasive route is chosen. It entails fewer conduit complications and lower mortality, Dr. Luketich said.

In this series, 49% of patients underwent a modified McKeown approach involving videothoracoscopic esophageal mobilization, laparoscopic conduit preparation, and neck anastomosis, whereas 51% were treated via the modified Ivor-Lewis approach.

This was a nonrandomized study, but patients in the two study arms were essentially the same in terms of baseline characteristics. In all, 95% were operated on for malignant disease, 80% were men, and 31% received preoperative chemotherapy and/or radiotherapy. Patients who were operated on in the most recent years of the series underwent the Ivor-Lewis approach because Dr. Luketich has come to prefer it. He noted that most trainees are more comfortable with it; they have far more experience with operating in the chest than the neck.

Furthermore, outcomes are better than results with the McKeown approach. Indeed, the 30-day mortality rate was just 1.2% with the Ivor-Lewis minimally invasive esophagectomy chest (MIE-chest) approach vs. 2.5% with the McKeown MIE-neck approach. The major morbidity rate was 31% in the MIE-chest group, significantly less than the 36% with the MIE-neck group. This difference was driven by the increased risk of laryngeal nerve injury with the McKeown approach. The incidence of vocal cord paresis or paralysis was 8% in the MIE-neck patients, compared with 1% in the MIE-chest group.

Rates of other complications were closely similar in the two groups: 6% for empyema, 5% for acute respiratory distress syndrome, 5% for pulmonary embolism, 2% for acute MI, 3% for heart failure, and 5% for anastomotic leak requiring surgery.

Quality of life assessments using the Short Form-36 indicate that by 90 days, post-MIE patients scored in the age-adjusted normal range. "I think by 90 days the patients have bounced back," Dr. Luketich added.

"Laparoscopy–VATS [video-assisted thoracic surgery]–chest anastomosis is now our preferred approach to most esophageal cancers," he concluded.

Discussant Dr. David J. Sugarbaker called Dr. Luketich’s study "a landmark paper."

"Dr. Luketich has ... developed a procedure that is rapidly becoming a standard of care worldwide. This is the largest experience reported to date," noted Dr. Sugarbaker, professor of surgical oncology and chief of the division of thoracic surgery at Brigham and Women’s Hospital and Harvard Medical School, Boston.

Dr. Luketich declared that he had no financial conflicts of interest. ☐

BOCA RATON, FLA. — Minimally invasive esophagectomy has advanced to the point where it offers significant advantages over open esophagectomy in terms of operative morbidity and mortality, judging by results of a single-center review of 980 cases.

Published series indicate that the operative mortality of open esophagectomy is 8%-21%, although a few high-volume medical centers have reported rates as low as 3%.

"There is a perception among patients and physicians that open esophagectomy is to be avoided at all costs because of it substantial morbidity," Dr. James D. Luketich said at the annual meeting of the American Surgical Association.

In his review of 980 consecutive, elective, nonurgent, minimally invasive esophagectomies, the 30-day mortality was just 1.8%. Median operative time was 6.7 hours, which dropped to 4 hours in cases that were not done by residents. The median ICU stay was 2.0 days, with a median hospital length of stay of 8 days. A median 21 lymph nodes were dissected, and 98% of cases had negative surgical margins.

"A less invasive surgical approach for esophageal cancer would improve the standard of care by reducing morbidity and shortening hospital stays and time to return to daily activities. If successful, surgeons might see more early-stage referrals from Barrett’s patients now in surveillance," added Dr. Luketich, professor of surgery and chief of the Heart, Lung and Esophageal Surgery Institute at the University of Pittsburgh Medical Center.

Using a modified Ivor-Lewis approach involving laparoscopic conduit preparation, videothoracoscopic esophageal mobilization, and an intrathoracic anastomosis is preferable to the McKeown approach when the minimally invasive route is chosen. It entails fewer conduit complications and lower mortality, Dr. Luketich said.

In this series, 49% of patients underwent a modified McKeown approach involving videothoracoscopic esophageal mobilization, laparoscopic conduit preparation, and neck anastomosis, whereas 51% were treated via the modified Ivor-Lewis approach.

This was a nonrandomized study, but patients in the two study arms were essentially the same in terms of baseline characteristics. In all, 95% were operated on for malignant disease, 80% were men, and 31% received preoperative chemotherapy and/or radiotherapy. Patients who were operated on in the most recent years of the series underwent the Ivor-Lewis approach because Dr. Luketich has come to prefer it. He noted that most trainees are more comfortable with it; they have far more experience with operating in the chest than the neck.

Furthermore, outcomes are better than results with the McKeown approach. Indeed, the 30-day mortality rate was just 1.2% with the Ivor-Lewis minimally invasive esophagectomy chest (MIE-chest) approach vs. 2.5% with the McKeown MIE-neck approach. The major morbidity rate was 31% in the MIE-chest group, significantly less than the 36% with the MIE-neck group. This difference was driven by the increased risk of laryngeal nerve injury with the McKeown approach. The incidence of vocal cord paresis or paralysis was 8% in the MIE-neck patients, compared with 1% in the MIE-chest group.

Rates of other complications were closely similar in the two groups: 6% for empyema, 5% for acute respiratory distress syndrome, 5% for pulmonary embolism, 2% for acute MI, 3% for heart failure, and 5% for anastomotic leak requiring surgery.

Quality of life assessments using the Short Form-36 indicate that by 90 days, post-MIE patients scored in the age-adjusted normal range. "I think by 90 days the patients have bounced back," Dr. Luketich added.

"Laparoscopy–VATS [video-assisted thoracic surgery]–chest anastomosis is now our preferred approach to most esophageal cancers," he concluded.

Discussant Dr. David J. Sugarbaker called Dr. Luketich’s study "a landmark paper."

"Dr. Luketich has ... developed a procedure that is rapidly becoming a standard of care worldwide. This is the largest experience reported to date," noted Dr. Sugarbaker, professor of surgical oncology and chief of the division of thoracic surgery at Brigham and Women’s Hospital and Harvard Medical School, Boston.

Dr. Luketich declared that he had no financial conflicts of interest. ☐

BOCA RATON, FLA. — Minimally invasive esophagectomy has advanced to the point where it offers significant advantages over open esophagectomy in terms of operative morbidity and mortality, judging by results of a single-center review of 980 cases.

Published series indicate that the operative mortality of open esophagectomy is 8%-21%, although a few high-volume medical centers have reported rates as low as 3%.

"There is a perception among patients and physicians that open esophagectomy is to be avoided at all costs because of it substantial morbidity," Dr. James D. Luketich said at the annual meeting of the American Surgical Association.

In his review of 980 consecutive, elective, nonurgent, minimally invasive esophagectomies, the 30-day mortality was just 1.8%. Median operative time was 6.7 hours, which dropped to 4 hours in cases that were not done by residents. The median ICU stay was 2.0 days, with a median hospital length of stay of 8 days. A median 21 lymph nodes were dissected, and 98% of cases had negative surgical margins.

"A less invasive surgical approach for esophageal cancer would improve the standard of care by reducing morbidity and shortening hospital stays and time to return to daily activities. If successful, surgeons might see more early-stage referrals from Barrett’s patients now in surveillance," added Dr. Luketich, professor of surgery and chief of the Heart, Lung and Esophageal Surgery Institute at the University of Pittsburgh Medical Center.

Using a modified Ivor-Lewis approach involving laparoscopic conduit preparation, videothoracoscopic esophageal mobilization, and an intrathoracic anastomosis is preferable to the McKeown approach when the minimally invasive route is chosen. It entails fewer conduit complications and lower mortality, Dr. Luketich said.

In this series, 49% of patients underwent a modified McKeown approach involving videothoracoscopic esophageal mobilization, laparoscopic conduit preparation, and neck anastomosis, whereas 51% were treated via the modified Ivor-Lewis approach.

This was a nonrandomized study, but patients in the two study arms were essentially the same in terms of baseline characteristics. In all, 95% were operated on for malignant disease, 80% were men, and 31% received preoperative chemotherapy and/or radiotherapy. Patients who were operated on in the most recent years of the series underwent the Ivor-Lewis approach because Dr. Luketich has come to prefer it. He noted that most trainees are more comfortable with it; they have far more experience with operating in the chest than the neck.

Furthermore, outcomes are better than results with the McKeown approach. Indeed, the 30-day mortality rate was just 1.2% with the Ivor-Lewis minimally invasive esophagectomy chest (MIE-chest) approach vs. 2.5% with the McKeown MIE-neck approach. The major morbidity rate was 31% in the MIE-chest group, significantly less than the 36% with the MIE-neck group. This difference was driven by the increased risk of laryngeal nerve injury with the McKeown approach. The incidence of vocal cord paresis or paralysis was 8% in the MIE-neck patients, compared with 1% in the MIE-chest group.

Rates of other complications were closely similar in the two groups: 6% for empyema, 5% for acute respiratory distress syndrome, 5% for pulmonary embolism, 2% for acute MI, 3% for heart failure, and 5% for anastomotic leak requiring surgery.

Quality of life assessments using the Short Form-36 indicate that by 90 days, post-MIE patients scored in the age-adjusted normal range. "I think by 90 days the patients have bounced back," Dr. Luketich added.

"Laparoscopy–VATS [video-assisted thoracic surgery]–chest anastomosis is now our preferred approach to most esophageal cancers," he concluded.

Discussant Dr. David J. Sugarbaker called Dr. Luketich’s study "a landmark paper."

"Dr. Luketich has ... developed a procedure that is rapidly becoming a standard of care worldwide. This is the largest experience reported to date," noted Dr. Sugarbaker, professor of surgical oncology and chief of the division of thoracic surgery at Brigham and Women’s Hospital and Harvard Medical School, Boston.

Dr. Luketich declared that he had no financial conflicts of interest. ☐

SAN ANTONIO – Partial fundoplication improves dysphagia and regurgitation symptom scores in those patients undergoing laparoscopic Heller myotomy for esophageal achalasia, regardless of whether the fundus is laid over the anterior esophagus or wrapped around the back of it, a multicenter study has shown.

Previous studies have demonstrated that partial fundoplication minimizes the likelihood of developing gastroesophageal reflux disease (GERD), but none has systematically compared the risks and benefits associated with wrapping the gastric fundus anterior to the esophagus (Dor fundoplication) or posterior to the esophagus (Toupet fundoplication), Dr. Arthur Rawlings said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

"The type of fundoplication that should be performed is controversial, and currently determined by surgeon’s choice rather than scientific evidence," he said. "Some surgeons advocate the Dor because they say it’s less complicated to perform, [avoids] the need for complete posterior dissection, completely disrupts the posterior esophageal ligament, and does cover the exposed esophageal mucosa." On the other hand, he noted, "other surgeons advocate for a Toupet fundoplication because it keeps the edges of the myotomy separated and possibly provides better reflux control."

To compare symptom frequency and severity as well as physiological differences associated with the two procedures, Dr. Rawlings of Washington University, St. Louis, and his colleagues conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five sites in 2003-2008 were randomized to the Dor or Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point (0-4) Likert scale preoperatively and at 2-6 weeks, 6 months, and 12 months postoperatively. They also evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a composite DeMeester pH score, he said.

Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12-month pH studies for 24 of the 49 patients who were randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure, Dr. Rawlings said. The results reported at the meeting represent those obtained for the patients for whom pH-testing results were available, he explained.

In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr. Rawlings said. "Statistically significant improvements were observed in both groups for all but heartburn and chest pain measures," he noted. Specifically, in the Dor group, the preoperative solid dysphagia, heartburn, and regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3 improved to 1.0, 0.3, and 0.1, respectively, he said.

There was no significant difference between the two groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid reflux was experienced by 42% of the Dor patients and just 21% of the Toupet patients, said Dr. Rawlings. The difference between the median DeMeester pH scores at 6 months for the Dor (7.2) and Toupet (2.2) groups did not reach statistical significance, he said.

In a subgroup analysis of individuals with abnormal reflux scores regardless of fundoplication procedure, "the only thing that fell out as significant was heartburn frequency and severity," Dr. Rawlings stated.

The findings indicate that both the Dor and Toupet procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings. The differences in pathological acid reflux between the two groups, though not statistically significant, "do support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure," he said.

This study was supported a SAGES research grant. Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.☐

SAN ANTONIO – Partial fundoplication improves dysphagia and regurgitation symptom scores in those patients undergoing laparoscopic Heller myotomy for esophageal achalasia, regardless of whether the fundus is laid over the anterior esophagus or wrapped around the back of it, a multicenter study has shown.

Previous studies have demonstrated that partial fundoplication minimizes the likelihood of developing gastroesophageal reflux disease (GERD), but none has systematically compared the risks and benefits associated with wrapping the gastric fundus anterior to the esophagus (Dor fundoplication) or posterior to the esophagus (Toupet fundoplication), Dr. Arthur Rawlings said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

"The type of fundoplication that should be performed is controversial, and currently determined by surgeon’s choice rather than scientific evidence," he said. "Some surgeons advocate the Dor because they say it’s less complicated to perform, [avoids] the need for complete posterior dissection, completely disrupts the posterior esophageal ligament, and does cover the exposed esophageal mucosa." On the other hand, he noted, "other surgeons advocate for a Toupet fundoplication because it keeps the edges of the myotomy separated and possibly provides better reflux control."

To compare symptom frequency and severity as well as physiological differences associated with the two procedures, Dr. Rawlings of Washington University, St. Louis, and his colleagues conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five sites in 2003-2008 were randomized to the Dor or Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point (0-4) Likert scale preoperatively and at 2-6 weeks, 6 months, and 12 months postoperatively. They also evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a composite DeMeester pH score, he said.

Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12-month pH studies for 24 of the 49 patients who were randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure, Dr. Rawlings said. The results reported at the meeting represent those obtained for the patients for whom pH-testing results were available, he explained.

In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr. Rawlings said. "Statistically significant improvements were observed in both groups for all but heartburn and chest pain measures," he noted. Specifically, in the Dor group, the preoperative solid dysphagia, heartburn, and regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3 improved to 1.0, 0.3, and 0.1, respectively, he said.

There was no significant difference between the two groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid reflux was experienced by 42% of the Dor patients and just 21% of the Toupet patients, said Dr. Rawlings. The difference between the median DeMeester pH scores at 6 months for the Dor (7.2) and Toupet (2.2) groups did not reach statistical significance, he said.

In a subgroup analysis of individuals with abnormal reflux scores regardless of fundoplication procedure, "the only thing that fell out as significant was heartburn frequency and severity," Dr. Rawlings stated.

The findings indicate that both the Dor and Toupet procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings. The differences in pathological acid reflux between the two groups, though not statistically significant, "do support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure," he said.

This study was supported a SAGES research grant. Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.☐

SAN ANTONIO – Partial fundoplication improves dysphagia and regurgitation symptom scores in those patients undergoing laparoscopic Heller myotomy for esophageal achalasia, regardless of whether the fundus is laid over the anterior esophagus or wrapped around the back of it, a multicenter study has shown.

Previous studies have demonstrated that partial fundoplication minimizes the likelihood of developing gastroesophageal reflux disease (GERD), but none has systematically compared the risks and benefits associated with wrapping the gastric fundus anterior to the esophagus (Dor fundoplication) or posterior to the esophagus (Toupet fundoplication), Dr. Arthur Rawlings said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

"The type of fundoplication that should be performed is controversial, and currently determined by surgeon’s choice rather than scientific evidence," he said. "Some surgeons advocate the Dor because they say it’s less complicated to perform, [avoids] the need for complete posterior dissection, completely disrupts the posterior esophageal ligament, and does cover the exposed esophageal mucosa." On the other hand, he noted, "other surgeons advocate for a Toupet fundoplication because it keeps the edges of the myotomy separated and possibly provides better reflux control."

To compare symptom frequency and severity as well as physiological differences associated with the two procedures, Dr. Rawlings of Washington University, St. Louis, and his colleagues conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five sites in 2003-2008 were randomized to the Dor or Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point (0-4) Likert scale preoperatively and at 2-6 weeks, 6 months, and 12 months postoperatively. They also evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a composite DeMeester pH score, he said.

Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12-month pH studies for 24 of the 49 patients who were randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure, Dr. Rawlings said. The results reported at the meeting represent those obtained for the patients for whom pH-testing results were available, he explained.

In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr. Rawlings said. "Statistically significant improvements were observed in both groups for all but heartburn and chest pain measures," he noted. Specifically, in the Dor group, the preoperative solid dysphagia, heartburn, and regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3 improved to 1.0, 0.3, and 0.1, respectively, he said.

There was no significant difference between the two groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid reflux was experienced by 42% of the Dor patients and just 21% of the Toupet patients, said Dr. Rawlings. The difference between the median DeMeester pH scores at 6 months for the Dor (7.2) and Toupet (2.2) groups did not reach statistical significance, he said.

In a subgroup analysis of individuals with abnormal reflux scores regardless of fundoplication procedure, "the only thing that fell out as significant was heartburn frequency and severity," Dr. Rawlings stated.

The findings indicate that both the Dor and Toupet procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings. The differences in pathological acid reflux between the two groups, though not statistically significant, "do support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure," he said.

This study was supported a SAGES research grant. Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.☐

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

SAN FRANCISCO – Endo­scopic resection may help man­agement of clinically node– negative superficial squamous cell carcinoma of the esophagus, new data from Japan suggest.

<[stk -1]>A retrospective study of 83 patients who had endoscopic re­section and subsequent treat­ment because of the depth of cancer invasion found a 5-year survival rate of 76% when fol­lowed by chemoradiation and 100% when followed by surgery.<[etk]>

<[stk -1]>The most common complica­tion of the endoscopic resection was stenosis, noted in 11% of cases overall, lead investigator Dr. Toshiro Iizuka, a gastroen­terologist at Toranomon Hospi­tal in Tokyo, reported at the meeting  on gastrointestinal can­cers sponsored by the American Society of Clinical Oncology.

“Endoscopic therapy plus ad­ditional treatment for M3 to SM2 superficial carcinoma of the esophagus did not entail the development of any serious complications. Thus, such com­bined treatment was safe and feasible,” Dr. Iizuka comment­ed. “The long-term follow-up results were fairly gratifying.”

“Surgical resection has been considered as a standard treat­ment in cases of superficial esophageal cancer with poten­tial lymph node metastasis,” but up to two-thirds of patients ex­perience serious complications.

<[stk -1]>“The frequency of lymph node metastases in superficial squamous cell carcinoma of the esophagus … depends on the depth of invasion,” said Dr. Iizu­ka. “Accordingly, a therapeutic strategy has become feasible whereby endoscopic submucos­al dissection aimed at local con­trol is undertaken first, followed by considering additional treat­ment based on the results of the histological examination.”<[etk]>

<[stk -1]>The patients all had T1 tu­mors and clinically node-nega­tive (cN0) status as determined by endoscopy, endoscopic ultra­sound, CT, and PET imaging. They had endoscopic resection, either endoscopic mucosal re­section (EMR) before March 2005 or endoscopic submucosal dissection (ESD) after.<[etk]>

<[stk -3]>Histologic evaluation of the endoscopically resected lesions showed that 140 patients had pathologic M3, SM1, or SM2 tu­mors, and they therefore received additional treatment. Patients found to have pathologic M1 or M2 tumors were followed.<[etk]>

Dr. Iizuka focused on results for 27 patients who underwent subsequent surgical resection and 56 who underwent subse­quent chemoradiation, with the choice between these two op­tions left to patients after dis­cussion of each in their case.

Overall, these patients had a mean age of about 63 years, and 87% were men. Tumors were roughly equally located in the upper, middle, and lower esophagus; the mean size was 42 mm in the surgery group and 26 mm in the chemoradia­tion group. The majority of en­doscopic resections were ESD.

In the surgery group, patients more often had a three-field lymph node dissection (59%) than a two-field one (41%). In the chemoradiation group, the majority of patients received 40-45 Gy of radiation (86%) and low-dose 5-fluorouracil and cis­platin chemotherapy (57%).

Results for all 140 patients who underwent endoscopic re­section showed a resection rate of 81% and an R0 resection rate of 72%. Overall, 15% of pa­tients had a complication from the procedure, with stenosis, at 11%, being the most common.

The main complications were anastomotic stenosis (15% of patients) and recurrent nerve palsy (7%). Also, 7% of patients were found to have residual can­cer and 4% were found to have lymph node metastases. The main serious complication of chemoradiation was grade 3 leukopenia (14%). There were no treatment-related deaths or grade 4 adverse events.

The median duration of fol­low-up was 42.5 months in the surgery group and 33 months in the chemoradiation group.

None of the patients had a lo­cal recurrence. The actuarial 5-year rates of relapse-free survival were 100% and 88%, re­spectively; the actuarial 5-year rates of overall survival were 100% and 76%, respectively.

Dr. Iizuka reported no rele­vant conflicts of interest.

SAN FRANCISCO – Endo­scopic resection may help man­agement of clinically node– negative superficial squamous cell carcinoma of the esophagus, new data from Japan suggest.

<[stk -1]>A retrospective study of 83 patients who had endoscopic re­section and subsequent treat­ment because of the depth of cancer invasion found a 5-year survival rate of 76% when fol­lowed by chemoradiation and 100% when followed by surgery.<[etk]>

<[stk -1]>The most common complica­tion of the endoscopic resection was stenosis, noted in 11% of cases overall, lead investigator Dr. Toshiro Iizuka, a gastroen­terologist at Toranomon Hospi­tal in Tokyo, reported at the meeting  on gastrointestinal can­cers sponsored by the American Society of Clinical Oncology.

“Endoscopic therapy plus ad­ditional treatment for M3 to SM2 superficial carcinoma of the esophagus did not entail the development of any serious complications. Thus, such com­bined treatment was safe and feasible,” Dr. Iizuka comment­ed. “The long-term follow-up results were fairly gratifying.”

“Surgical resection has been considered as a standard treat­ment in cases of superficial esophageal cancer with poten­tial lymph node metastasis,” but up to two-thirds of patients ex­perience serious complications.

<[stk -1]>“The frequency of lymph node metastases in superficial squamous cell carcinoma of the esophagus … depends on the depth of invasion,” said Dr. Iizu­ka. “Accordingly, a therapeutic strategy has become feasible whereby endoscopic submucos­al dissection aimed at local con­trol is undertaken first, followed by considering additional treat­ment based on the results of the histological examination.”<[etk]>

<[stk -1]>The patients all had T1 tu­mors and clinically node-nega­tive (cN0) status as determined by endoscopy, endoscopic ultra­sound, CT, and PET imaging. They had endoscopic resection, either endoscopic mucosal re­section (EMR) before March 2005 or endoscopic submucosal dissection (ESD) after.<[etk]>

<[stk -3]>Histologic evaluation of the endoscopically resected lesions showed that 140 patients had pathologic M3, SM1, or SM2 tu­mors, and they therefore received additional treatment. Patients found to have pathologic M1 or M2 tumors were followed.<[etk]>

Dr. Iizuka focused on results for 27 patients who underwent subsequent surgical resection and 56 who underwent subse­quent chemoradiation, with the choice between these two op­tions left to patients after dis­cussion of each in their case.

Overall, these patients had a mean age of about 63 years, and 87% were men. Tumors were roughly equally located in the upper, middle, and lower esophagus; the mean size was 42 mm in the surgery group and 26 mm in the chemoradia­tion group. The majority of en­doscopic resections were ESD.

In the surgery group, patients more often had a three-field lymph node dissection (59%) than a two-field one (41%). In the chemoradiation group, the majority of patients received 40-45 Gy of radiation (86%) and low-dose 5-fluorouracil and cis­platin chemotherapy (57%).

Results for all 140 patients who underwent endoscopic re­section showed a resection rate of 81% and an R0 resection rate of 72%. Overall, 15% of pa­tients had a complication from the procedure, with stenosis, at 11%, being the most common.

The main complications were anastomotic stenosis (15% of patients) and recurrent nerve palsy (7%). Also, 7% of patients were found to have residual can­cer and 4% were found to have lymph node metastases. The main serious complication of chemoradiation was grade 3 leukopenia (14%). There were no treatment-related deaths or grade 4 adverse events.

The median duration of fol­low-up was 42.5 months in the surgery group and 33 months in the chemoradiation group.

None of the patients had a lo­cal recurrence. The actuarial 5-year rates of relapse-free survival were 100% and 88%, re­spectively; the actuarial 5-year rates of overall survival were 100% and 76%, respectively.

Dr. Iizuka reported no rele­vant conflicts of interest.

SAN FRANCISCO – Endo­scopic resection may help man­agement of clinically node– negative superficial squamous cell carcinoma of the esophagus, new data from Japan suggest.

<[stk -1]>A retrospective study of 83 patients who had endoscopic re­section and subsequent treat­ment because of the depth of cancer invasion found a 5-year survival rate of 76% when fol­lowed by chemoradiation and 100% when followed by surgery.<[etk]>

<[stk -1]>The most common complica­tion of the endoscopic resection was stenosis, noted in 11% of cases overall, lead investigator Dr. Toshiro Iizuka, a gastroen­terologist at Toranomon Hospi­tal in Tokyo, reported at the meeting  on gastrointestinal can­cers sponsored by the American Society of Clinical Oncology.

“Endoscopic therapy plus ad­ditional treatment for M3 to SM2 superficial carcinoma of the esophagus did not entail the development of any serious complications. Thus, such com­bined treatment was safe and feasible,” Dr. Iizuka comment­ed. “The long-term follow-up results were fairly gratifying.”

“Surgical resection has been considered as a standard treat­ment in cases of superficial esophageal cancer with poten­tial lymph node metastasis,” but up to two-thirds of patients ex­perience serious complications.

<[stk -1]>“The frequency of lymph node metastases in superficial squamous cell carcinoma of the esophagus … depends on the depth of invasion,” said Dr. Iizu­ka. “Accordingly, a therapeutic strategy has become feasible whereby endoscopic submucos­al dissection aimed at local con­trol is undertaken first, followed by considering additional treat­ment based on the results of the histological examination.”<[etk]>

<[stk -1]>The patients all had T1 tu­mors and clinically node-nega­tive (cN0) status as determined by endoscopy, endoscopic ultra­sound, CT, and PET imaging. They had endoscopic resection, either endoscopic mucosal re­section (EMR) before March 2005 or endoscopic submucosal dissection (ESD) after.<[etk]>

<[stk -3]>Histologic evaluation of the endoscopically resected lesions showed that 140 patients had pathologic M3, SM1, or SM2 tu­mors, and they therefore received additional treatment. Patients found to have pathologic M1 or M2 tumors were followed.<[etk]>

Dr. Iizuka focused on results for 27 patients who underwent subsequent surgical resection and 56 who underwent subse­quent chemoradiation, with the choice between these two op­tions left to patients after dis­cussion of each in their case.

Overall, these patients had a mean age of about 63 years, and 87% were men. Tumors were roughly equally located in the upper, middle, and lower esophagus; the mean size was 42 mm in the surgery group and 26 mm in the chemoradia­tion group. The majority of en­doscopic resections were ESD.

In the surgery group, patients more often had a three-field lymph node dissection (59%) than a two-field one (41%). In the chemoradiation group, the majority of patients received 40-45 Gy of radiation (86%) and low-dose 5-fluorouracil and cis­platin chemotherapy (57%).

Results for all 140 patients who underwent endoscopic re­section showed a resection rate of 81% and an R0 resection rate of 72%. Overall, 15% of pa­tients had a complication from the procedure, with stenosis, at 11%, being the most common.

The main complications were anastomotic stenosis (15% of patients) and recurrent nerve palsy (7%). Also, 7% of patients were found to have residual can­cer and 4% were found to have lymph node metastases. The main serious complication of chemoradiation was grade 3 leukopenia (14%). There were no treatment-related deaths or grade 4 adverse events.

The median duration of fol­low-up was 42.5 months in the surgery group and 33 months in the chemoradiation group.

None of the patients had a lo­cal recurrence. The actuarial 5-year rates of relapse-free survival were 100% and 88%, re­spectively; the actuarial 5-year rates of overall survival were 100% and 76%, respectively.

Dr. Iizuka reported no rele­vant conflicts of interest.

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest.