General Surgery News: August 2021 by McMahon Group

CONVENTION ISSUE

Society of American Gastrointestinal and Endoscopic Surgeons

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

August 2021 • Volume 48 • Number 8

Surgery for Diverticulitis: Who, When and How Still Up for Debate

Should Disappearing Colorectal Liver Metastases Be Resected?

By CHRISTINA FRANGOU

By KATE O’ROURKE

olorectal surgeons at the 2021 annual meeting of the American Society of Colon and Rectal Surgeons recommended a new approach to an old dilemma: what to do for patients with diverticulitis. Today, the management options for patients with this disease are more varied than in the past and still evolving, according to the panelists. They urged physicians to consider patients’ goals and disease severity, as well as surgeon and system factors, when weighing treatment options. Management of diverticulitis has

ow should disappearing colorectal liver metastases be managed? This topic was debated at the Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care by Thomas Aloia, MD, the vice president and director of the oncology service at Ascension Health, in Houston, and Laleh Melstrom, MD, MS, an assistant professor of surgery and immuno-oncology at City of Hope National Medical Center in Glendora, Calif.

Disappearing Liver Mets Should Be Resected Dr. Aloia said term definitions are critical to the discussion. Disappearing liver metastases respond to preoperative therapy but are still visible on high-quality liver imaging. This differs from disappeared liver metastases, which are not visible on high-quality liver imaging but detectable in the OR, and

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Ridesharing Linked To Lower Rates of Vehicle Crash Trauma

OPINION

Dear Intern:

Inflammation Everywhere

If You Could Go Back to Day 1, What Would You Tell Yourself?

By JENNA BASSETT, PhD

By ALLEABELLE GONGOLA, MD

By HENRY BUCHWALD, MD, PhD

Acute Inflammation

ates of motor vehicle crash trauma and impaired driving convictions fell in relation to the introduction of ridesharing services in Texas, according to a new study. The use of ridesharing services supported reductions in motor vehicle crash trauma trau and convictions for impaired driving in Houston, as reported by the study pub published in JAMA Surgeryy (202 (2021;e212227). “Tr “Traumatic injuries are one o of the leading causes of death

single quote can have an impact for years. I have a habit of writing down proverbs h ffrom coaches, books and podcasts so that I can draw on them as sources of inspiration. They are on notecards on my wall, the top lines on my daily to-do lists and backgrounds on my laptop. Almost a decade ago, during my senior year of high school, I was sitting in my own

hen I started as a practitioner, r, I understood inflammation too mean an acute response to trauma (e.g.,, tissue-penetrating injury) or a pathogen n (e.g., streptococcal bacteria). This response nse consisted of a plasma cellular compo-nent, a vascular effect and immune system participation. The immediate granulocyte cellular involvement is primarily by neutrophils, and under certain circumstances basophils or eosinophils, followed by mononuclear macrophages. Vasodilation occurs first at the arteriole level, followed by capillary dilation, resulting

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Continued on page 32

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OPINION

AUGUST 2021 / GENERAL SURGERY NEWS

To the 2021 Graduating Chief Resident and Fellow By FREDERICK L. GREENE, MD B

lthough your thoughts are now aimed at fellowship or a practice opportunity, I wanted to keep up my tradition of writing to you as you complete this important milestone in your surgical career. Now, even though the graduation dinner, chief ’s roast and traditional hoopla may have been somewhat muted because of these days of the COVID-19 pandemic, you can at least take solace in the fact that all who love and cherish you are very proud of your accomplishments. Now you can begin to focus on the issues that you will face in the coming years. If you are part of that vast majority of your graduating colleagues, you are embarking on or have completed a fellowship in a specialty that will hopefully give you many years of pleasure and deepen your commitment to your practice, whether it be in the community or academic setting or a blending of both. You probably have chosen a discipline—colorectal, plastics, vascular, trauma/ surgical critical care, etc.—because it represents a defined body of knowledge that you can wrap your arms around and could refine your skills, or it may hold promise for a lifestyle that fits you well and serves the needs of your loved ones. If you are in that minority of your graduating cadre who will embark directly on surgical

Senior Medical Adviser Frederick L. Greene, MD Charlotte, NC

practice in an urban or rural setting, it will probably be a challenging transition, since your residency or fellowship has only begun to prepare you for the experiences and responsibilities that you will face during the next 30 to 40 years of your career. So, what can I tell you, a bright, energetic, newly minted surgeon in your early or mid-30s, that you do not already know? The first thing is to not take yourself too seriously. This is a bit of a conundrum since you will have serious responsibilities, but it is important to remember that everyone can be replaced. As Charles de Gaulle said, “The cemeteries are full of indispensable people.”

‘Go out and do well, but more importantly ... go out and do good!’

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

Peter K. Kim, MD Bronx, NY

Editorial Advisory Board

Lauren A. Kosinski, MD Chestertown, MD

Gina Adrales, MD, MPH Baltimore, MD

Marina Kurian, MD New York, NY

Maurice Arregui, MD Indianapolis, IN

Raymond J. Lanzafame, MD, MBA Rochester, NY

Philip S. Barie, MD, MBA New York, NY

Timothy Lepore, MD Nantucket, MA

L.D. Britt, MD, MPH Norfolk, VA

Robert Lim, MD Tulsa, OK

James Forrest Calland, MD Charlottesville, VA

John Maa, MD San Francisco, CA

The humility of this stance will offer you some shelter from the burdens of the commitments you will make to your patients and from reckoning with your own imperfections. The second thing is to be kind to each other and to everyone with whom you come into contact in the hospital setting. To paraphrase Maya Angelou, people may not remember what you did or said, but they will always remember how you made them feel. You will be busy in your practice, but try not to neglect spending time with family. Do not let your intensity cause you to forget the central concerns of life. Make time to spend with your spouse, your children, and others who are important to you and who help you maintain your frame of mind and “aequanimitas.” If you’re lucky enough to have your parents or grandparents around, always give them your time and return the love they showed to you over the years as they supported you throughout your education. Use modern technology that you have at your fingertips to stay in touch frequently with those who you love and cherish. Remember to organize your time well to include educational and organizational activities that are meaningful. Finally, my greatest wish for you as you leave the protective environment of your residency or fellowship is that you not only go out and do well, but more importantly, that you go out and do good! ■

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IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2021

Bariatric Surgery Reduces Cravings

Factors for Diabetes Relapse After Bariatric Surgery Remission

By KATE O’ROURKE

leeve gastrectomy and Roux-en-Y gastric bypass are associated with a similar reduction in food cravings, according to new research. The findings were presented at the annual meeting of the American Society for Metabolic and Bariatric Surgery (abstract A013). According to Afton Koball, PhD, a clinical health psychologist at Gundersen Health System, in La Crosse, Wis., who presented the study, food cravings are defined as an intense desire to consume a particular food or food type that is difficult to resist. In the new study, Dr. Koball and her colleagues examined food cravings after RYGB or sleeve gastrectomy in patients at Gundersen Health System. They had intended to include all patients who had an initial evaluation for these procedures between May 2017 and July 2019, but the study was stopped early due to the COVID-19 pandemic. The researchers excluded patients who did not complete the Food Craving Inventory, a self-reported measure, both preoperatively and postoperatively. This inventory includes information on 25 food items regarding cravings and consumption. It has four food class scores: high fats, sweets, carbohydrates/starches and fast-food fats. Study participants completed the Food Craving Inventory preoperatively, and then at three, six, nine and 12 months after surgery. There were 206 individuals in the study, with a roughly equal split between RYGB and sleeve gastrectomy. The mean age was 46 years, the mean body mass index was 46.7 kg/m2, and 84% of the cohort was female. The researchers found a decrease in overall score preoperatively to all time points postoperatively (P<0.001) (Figure). This trend was seen for all four food class scores. There was generally no significant relationship between excess weight loss and food cravings after bariatric surgery. Food Craving Inventory Overall Score 5.0

Mean FCI II Score

esults from a registry-based cohort study, presented at the 2021 annual meeting of the American Society for Metabolic and Bariatric Surgery, has identified factors affecting relapse of type 2 diabetes after initial remission after bariatric surgery (abstract A007). Researchers said risk factors include longer preoperative diabetes duration, higher preoperative hemoglobin (Hb)A1c, preoperative insulin treatment, female sex and less postoperative weight loss. According to lead study author Anders Jans, MD, a general surgeon from Örebro University Hospital, in Örebro, Sweden, who presented the study, while many studies have identified different factors related to type 2 diabetes remission after bariatric surgery, less is known about factors that may influence diabetes relapse after initial remission. To conduct their study, Dr. Jans and his colleagues relied on the Scandinavian Obesity Surgery Registry. They included adults with type 2 diabetes and a body mass index of at least 35 kg/m2 who underwent a primary Roux-en-Y gastric bypass or sleeve gastrectomy between 2007 and 2015 and experienced a complete type 2 diabetes remission at two years postoperatively. Relapse was defined as a reintroduction of diabetes medication. Of the 3,595 patients who had HbA1c available at two-year follow-up, 2,090 had a complete remission, 429 had a partial remission, 428 had controlled diabetes and 648 had diabetes. A large majority of the patients with a complete remission (96.3%) had a gastric bypass. At five years, there were 1,364 patients available for follow-up, and at eight years, there were 334 patients available for follow-up. Factors for type 2 diabetes relapse included: • diabetes duration (years prior to surgery, adjusted hazard ratio [HR], 1.09; 95% CI, 1.05-1.14; P<0.001); • higher preoperative HbA1c (adjusted HR, 1.01; 95% CI, 1.00-1.02; P=0.013); • preoperative insulin treatment (adjusted HR, 2.87; 95% CI, 1.84-3.90; P<0.001); • female sex (adjusted HR, 0.65; 95% CI, 0.46-0.91; P=0.012); and • less postoperative weight loss one year after surgery (adjusted HR, 0.93; 95% CI, 0.91-0.96; P<0.001). “In the multivariable Cox regression analysis, we didn’t find that age, BMI, education or surgical method were significant risk factors for diabetes relapse,” Dr. Jans said. He said a study published last year on relapse after remission after bariatric surgery produced results that were mostly consistent with his study’s results (Diabetes Care 2020;43[3]:534-550). “This further supports our analysis, and, hopefully, these results can be used for clinical guidance,” Dr. Jans said. ■

Bariatric Surgery Reduces Stroke Risk in Short and Long Term By KATE O’ROURKE

4.0 3.0 2.0 1.0 0 Pre-op

3 mo.

6 mo.

9 mo.

12 mo.

n=206

n=149

n=120

n=99

n=92

Time Point P<0.001 for mean FCI score ar 3, 6, 9 and 12 months compared with preoperative mean FCI score.

“Increasing excess weight loss is modestly associated with reduced cravings for sweet and fast food at three months postop only,” Dr. Koball said. “Overall food cravings decreased over time, most significantly in the first three months. There was little evidence for differences in food cravings between sleeve and bypass over the first year postoperatively.” Dr. Koball said the study was limited in that it was a small sample size, a homogeneous sample and conducted at one institution. She said prior studies have shown mixed results regarding extra weight loss after bariatric surgery and cravings, with some studies showing no relationship between cravings and extra weight loss and others showing a negative or positive relationship (Surg Obes Relat Dis 2017;13[2]:220226; Br J Health Psychol 2018;23[3]:532-543; Eat Behav ■ 2012;13[4]:366-370).

ariatric surgery appears to reduce the risk for ischemic stroke at short- and long-term intervals, according to new research. The findings were presented at the 2021 annual meeting of the American Society for Metabolic and Bariatric Surgery (abstract A002). According to Michael Williams, MD, a surgical resident at Rush University Medical Center, in Chicago, who presented the study, while it is known that bariatric surgery improves many comorbid conditions, bariatric surgery’s impact on stroke risk is unclear. To shed light on this issue, Dr. Williams and his colleagues launched a study to determine the risk for ischemic stroke after surgery compared with risk in patients with similar degrees of obesity who did not undergo bariatric surgery. They accessed the Mariner Database (PearlDiver Inc.), a database that contains information on more than 120 million patients, for information on patients between 2010 and 2019. The researchers first identified patients who would be eligible for bariatric surgery by selecting those with a body mass index of 40 kg/m2 or greater or those with a BMI of 35 to 39 kg/m2 and a qualifying comorbidity. They then divided the study cohorts into those who underwent surgery, sleeve gastrectomy or Roux-en-Y gastric bypass, or those who did not undergo bariatric surgery. They performed coarsened exact matching based on BMI and comorbidities and used logistic regression analysis to determine the effect of bariatric surgery on the risk for stroke at one, three and five years after surgery. After including only those patients who were active in the database for a full year before and after surgery, there were 70,655 individuals in the bariatric surgery cohort and 1,322,327 in the control group. With coarsened exact matching based on BMI and comorbidities, the one-year stroke risk was 0.6% in the bariatric surgery group (n=56,514) and 1.2% in the control group (n=56,514) (odds ratio [OR], 0.54; 95% CI, 0.47-0.61). The three-year stroke risk was 2.1% in the bariatric surgery group (n=44,948) and 2.2% in the control group (n=44,948) (hazard ratio, 0.96; 95% CI, 0.91-1.00). The five-year stroke risk was 2.8% in the bariatric surgery group (n=27,619) and 3.6% in the control group (n=27,619) (OR, 0.78; 95% CI, 0.65-0.90). “Stroke is a very important cardiovascular event that has a low incidence, and so as a result, all previous studies have aggregated stroke with other major cardiovascular events,” said Corrigan McBride, MD, the chief of minimally invasive surgery and bariatric surgery at the University of Nebraska Medical Center, in Omaha, who served as the discussant at the meeting. “This study is particularly important because you were able to leverage a large database, and therefore accumulate numbers that would allow evaluation of stroke as a stand-alone end point at one, three and five ■ years,” Dr. McBride said.

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THE SCIENCE BEHIND POSITIVE PATIENT OUTCOMES

Innovations in Open Stapling: The GIA™ Stapler With Tri-Staple™ Technology Ryan K. Jones, MD Colorectal Surgeon Norton Women’s and Children’s Hospital Louisville, Kentucky

Advances in Open Surgical Stapling Three-row staplers with graduated compression have been widely adopted for a range of laparoscopic procedures.1 These staplers provide secure closures at the staple line that stop bleeding while permitting the perfusion that is necessary for healing.1 A linear stapler with 3 (vs 2) rows of staples is driving a comparable evolution in open procedures that can provide an added level of confidence, even for experienced surgeons.2 Ryan K. Jones, MD, a colorectal surgeon at Norton Women’s and Children’s Hospital, in Louisville, Kentucky, estimates that 80% of his procedures are performed laparoscopically or robotically. When an open approach is necessary, however, he has found the introduction of graduated-height 3-row stapling to be a meaningful advance.2

Making the Switch Dr Jones uses the GIA™ stapler with Tri-Staple™ technology (Figure 1) for side-to-side anastomoses in open resections of the small and large bowel. Already convinced of the benefits of 3 rows of staples for achieving a reliable staple line in laparoscopic surgery, he switched from 2-row linear staplers in open procedures to the first Tri-Staple™ open linear device soon after it became available.1 “I was eager to move to the GIA™ open device,” Dr Jones said. In fact, his interest with the GIA™ stapler with Tri-Staple™ technology may have influenced other

surgeons at his hospital and health system, some of whom were experiencing leaks in open colorectal procedures with a 2-row linear stapler that predominated when Dr Jones arrived.2,a In the context of these complications, Dr Jones’ experience with the advantages of Tri-Staple™ technology “led the hospital system to open it up to other surgeons. Those who had experienced complications with the 2-row linear staplers were the most interested, and after they switched, the feedback was very positive,” he said. “They reported improved confidence in the firings.”

Dry Staple Lines Although Dr Jones was not experiencing leaks with 2-row staplers in open surgery, he would sometimes observe ooze along the staple line. He considers even modest evidence of an imperfect closure to represent an unacceptable risk for hematoma and an unwanted event that can delay completion of a case. Since switching to the GIA™ stapler with Tri-Staple™ technology, he has not observed bleeding at the staple line in the lumen of the anastomosis (Figure 2).3 “This has meant no oversewing of the closure line,” Dr Jones said. “There is always a risk of introducing a new injury with additional suturing, a problem that is avoided with dry staple lines.” The “peace of mind” that Dr Jones gets from the absence of bleeding at the staple line, however, is not the only characteristic of the GIA™ stapler with Tri-Staple™ technology from which he derives reassurance.

to open cases,” he said. “The extra row is reassuring.” The advantages of the GIA™ stapler with Tri-Staple™ technology also derive from the graduated staple heights inherent to the technology.2 The first row contains the shortest staples and creates a secure seal, while “the greater height of the second and third rows avoids the barrier to perfusion, which is essential to healing,” Dr Jones said.1,4,b Tri-Staple™ technology provides 50% more staples than the GIA™ stapler with DST Series™ technology and other 2-row linear cutters.5,c In addition, manufacturer studies and an in vivo experiment using micro-CT imaging validate improved perfusion from graduated-height staples.1,4,b The latter study demonstrated higher perfusion volumes with graduatedheight staples than a single staple line in an animal model.1,b Three rows of varied-height staples in the stepped cartridge face also generate less stress on tissue during compression and clamping.6,d “The graduated height lends itself to a more favorable compression

The Technology 3 Rows of Varied-Height Staples Dr Jones prefers a third row of staples for that peace of mind he describes. “I appreciated this concept in laparoscopic staplers, and it’s also relevant

Figure 2. Dr Jones has experienced less bleeding at the staple line compared with his former 2-row stapler. Figure 1. The GIA™ stapler with Tri-Staple™ technology.

GENERAL SURGERY NEWS • AUGUST 2021

Based on reference 3.

Supported by

Three rows provide 50% more staples,10,c and cartridges can be selected for optimal tissue thickness.5 The design reduces tissue stress during compression and clamping,6,d and a fresh blade with every firing ensures accurate and reliable cutting.5 According to Dr Jones, the new device brings the advantages of laparoscopic Tri-Staple™ technology to procedures performed with an open approach. “I have substantial experience with 3-row laparoscopic staplers. I saw the advantages of this approach, so I was happy to see this become available in the open setting,” he said.

of the tissue,” Dr Jones said. “By pushing fluid away from the staple line, it reduces pressure on the tissue when the stapler is fired.”

Numerous features improve the experience of surgeons beyond the advantages of Tri-Staple™ technology. For example, the retraction force is approximately 70% less with the GIA™ stapler with Tri-Staple™ technology than the GIA™ stapler with DST Series™ technology.7,e Although Dr Jones might need to apply extra pressure for firing in thicker tissue or when 1 staple line crosses another, he does not believe this is unexpected of a stapler laying down 3 staple rows, and it has never impaired his firing ability. “I like the feel of the device. It’s easy to hold and maneuver,” Dr Jones said. He added that features, such as a large firing knob8,a and a new knife blade with each firing, enhance usability and that the palm is used to fire the device, which provides a controlled application of pressure. “I don’t want to have any risk of the tissue tearing. I have had staplers that did not cut appropriately, which causes problems or the need for a redo,” Dr Jones said. “The new blade with every firing provides an extra level of confidence, even when stapling thick tissue.”5

longer stapler cartridges, you can get an extra couple of centimeters without a second firing, which can make the procedure more efficient,” Dr Jones said.9,c Internal manufacturer testing associates the GIA™ stapler with Tri-Staple™ technology with an 8% to 11% greater likelihood of completing a transection in a single firing.9,c Both the 80- and 60-mm lengths can be used in up to 8 firings per procedure,2 and with interchangeable cartridges across a broad range of tissue thickness.5 “It is extremely easy to change cartridges. The scrub tech can do it with very little downtime, which is good for workflow,” Dr Jones said. “It’s helpful to have a choice of staple heights, which I think reduces the chance of misfiring on thicker tissue,” Dr Jones said. The purple cartridge is for medium/thick tissue, with staple heights of 3.0, 3.5, and 4.0 mm. For thicker tissue, the black cartridge provides staple heights of 4.0, 4.5, and 5.0 mm, which is the largest among available open staplers (Figure 3).5,c “The cartridges provide a great deal of flexibility. I typically use the purple load for smallbowel and colon resections, but the black cartridge lets you tackle thicker tissue.5,c Although you generally make the cartridge choice during preoperative planning, there is no problem if you change your mind at the start of the case,” Dr Jones said.

Interchangeable Cartridges

Conclusion

Medtronic is developing Tri-Staple™ cartridges with a variety of staple heights and cartridge lengths. Today, cartridges come in 2 sizes and are color-coded for staple heights. Of the 2 lengths currently available, (60 and 80 mm), the 80-mm cartridge is the longest available with Tri-Staple™ technology. “With the

A decade after triple-row stapling was introduced for minimally invasive surgery, the GIA™ stapler with Tri-Staple™ technology has brought the same sophistication to open procedures.2 The graduated staple heights provide a secure closure while leaving room for the perfusion needed for healing.1

User-Friendly Features

Preclinical results may not correlate with clinical performance in humans.

Compared with the GIA™ staplers with DST Series™ technology, Ethicon Linear Cutter, and Ethicon Proximate™ Linear Cutter.

Compared with the GIA™ stapler with DST Series™ technology and Ethicon Proximate™ Linear Cutter.

Compared with the GIA™ stapler with DST Series™ technology, Ethicon Linear Cutter, Ethicon Proximate™ Linear Cutter, Frankenman Chex™ Linear Cutter Stapler, and Panther Linear Cutter Stapler.

References 1. Eschbach M, Sindberg GM, Godek ML, et al. Micro-CT imaging as a method for comparing perfusion in graduated-height and single-height surgical staple lines. Med Devices. 2019;11:267-273. 2. Data on file. 80 mm GIA™ Stapler with Tri-Staple™ technology purple and black design verification report. Report #RE00171002 rev 0. Medtronic; August 14, 2019. 3. Data on file. Comparison of hemostasis: black cartridge. Report #RE00292655. Medtronic; September 16, 2020. 4. Data on file. Endo GIA™ Tri-Staple™ testing performed and design similarities between Lily and Endo GIA™ Tri-Staple™ technology memo. Report #RE00222215. Medtronic; October 16, 2019. 5. Data on file. R&D memo. Report #RE00218526. Medtronic; August 27, 2019. 6. Data on file. Lily tissue compression comparison. Report #RE00231875. Medtronic; December 4, 2019. 7. Data on file. Comparison of retraction force. Report #RE00292134. Medtronic; September 14, 2020. 8. Data on file. Firing knob for GIA™ Stapler with Tri-Staple™ Technology. Report #RE00241961. Medtronic; July 7, 2020. 9. Data on file. Cutting length comparison. Report #RE00279157. Medtronic; July 7, 2020. 10. Data on file. Security versus two-row linear staplers and Ethicon TLC linear cutter. Report #RE00280804. Medtronic; July 14, 2020.

06/2021-US-ST-2100115

Based on reference 5.

Compared with the GIA™ stapler with DST Series™ technology.

Disclosure: Dr Jones reported no relevant financial disclosures. This is one surgeon’s experience, results, and recommendations. Results may vary from surgeon to surgeon. Please see the package insert for the complete list of indications, warnings, precautions, and other important medical information.

GENERAL SURGERY NEWS • AUGUST 2021

BB214

Figure gure 3. The GIA™ purple stapler with Tri-Staple™ technology is for medium/thick medium/thic tissue (staple heights: 3.0, 3.5, and 4.0 mm). The black cartridge is for thicker tissue and provides the largest open staple height available (staple heights: 4.0, 4.5, and 5.0 mm).c

IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2021

Axillary Surgery Deescalation Possible for Some After Neoadjuvant Chemo By KATE O’ROURKE

atients who are cN0 with HER2positive or triple-negative breast cancer who receive full neoadjuvant chemotherapy may be ideal candidates for axillary surgery deescalation if they have a breast pathologic complete response (pCR), according to a new study. The findings were presented at the Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care (abstract 12). Deescalation of axillary surgery demands careful patient selection. In the new study, researchers sought to refine patient selection criteria for deescalating axillary surgery. To achieve their aim, the researchers led by Anna Weiss, MD, a surgical oncologist with Brigham and Women’s Hospital and Dana-Farber Cancer Institute, in Boston, focused on two clinical trials: Cancer and Leukemia Group B (CALGB) 4061 and CALGB 40603. Previous results from the two trials reported the trials’ primary end points of pCR rates after neoadjuvant chemotherapy in patients with HER2-positive and triple-negative breast cancer (J Clin Oncol 2020;38[35]:4184-4193; J Clin Oncol 2015;33[1]:13-21). To determine factors associated with pathologic node-negative status (ypN0), Dr. Weiss and her colleagues analyzed

760 patients with stage II to III HER2positive or triple-negative breast cancer in the two trials. They excluded patients with pre-neoadjuvant chemotherapy sentinel or axillary lymph node dissection (n=122), missing cN (n=58) or ypN status (n=41). Of the 539 patients who met the criteria, 45% presented with cN0 disease, 44% presented with cN1 and 11% presented with cN2-3. Among pre-neoadjuvant chemotherapy cN0 patients, 89% were ypN0, including 96% of those with breast pCR and 83% of those with breast residual disease. Only 4% of cN0 patients who experienced a breast pCR were ypN-positive. Among pre-neoadjuvant chemotherapy cN1, 66% were ypN0 (experienced nodal pCR), including 92% of those with a breast pCR and 40% of those with breast residual disease. Lastly, among cN2-3 patients, 66% were ypN0, including 88% of those with breast pCR and 37% of those with breast residual disease. On multivariable analysis, the only factors associated with ypN0 status were clinical nodal category and breast response (both P<0.0001). “Patients with HER2-positive or triple-negative breast cancer who are cN0 and experience a breast pCR may be ideal candidates for axillary surgery deescalation. This trial supports the incorporation of deescalated axillary surgery

strategies in future neoadjuvant chemotherapy trials,” Dr. Weiss said. She said more research is needed to define the optimal patient for axillary surgery deescalation after neoadjuvant chemotherapy, including long-term clinical outcomes. Asked to comment on the study, Monica Morrow, MD, the chief of the breast service at Memorial Sloan Kettering Cancer Center (MSKCC), and a professor of surgery at Weill Medical College of Cornell University, both in New York City, said the study confirms, in a data set from a clinical trial, other observations regarding nodal response to neoadjuvant chemotherapy: Patients who start out clinically nodenegative are more likely to have pathologically negative nodes than those who are node-positive, and breast pCR and nodal pCR are related. “Of note, 40% of patients who were node-positive prior to neoadjuvant chemotherapy and did not have a breast pCR had a nodal pCR. Thus, lack of a breast pCR is not a reason to subject patients to axillary dissection rather than sentinel node biopsy,” Dr. Morrow said. “In

contrast, 8% of cN1 patients who had a breast pCR had residual nodal disease, so breast pCR doesn’t allow you to avoid nodal staging in this group. In the cN0 patients, 4% of those with breast pCR had residual disease. Whether it makes sense to avoid axillary surgery in this group and return those who didn’t have a breast pCR to the OR for a second operation on the axilla is a research question.” “This is an interesting study, as it examines clinicopathologic factors that could be used to identify patients most likely to have a negative nodal status after neoadjuvant chemotherapy,” said Tracy-Ann Moo, MD, an associate attending surgeon with the breast service at MSKCC. “The authors show that those patients with no clinical evidence of lymph node involvement prior to neoadjuvant chemotherapy and no evidence of residual disease in the breast after neoadjuvant chemotherapy are most likely to have pathologic negative lymph nodes at the time of surgery. This is important as we try to determine which patients might be candidates for a more limited surgical approach to the axilla post-neoadjuvant chemotherapy.” ■

Wrist Monitors Track Upper Limb Function After Breast Surgery By MONICA J. SMITH

earable activity monitors may be more reliable and objective than other means of assessing upper limb functioning after breast cancer treatment, and may be able to help patients and their doctors monitor recovery, according to new research. “This is very original and something we don’t usually think about,” commented Eli Avisar, MD, a professor of surgery at the University of Miami Miller School of Medicine.

‘Quantifying the morbidity of different treatments may help to track upper limb recovery and help the clinician and patient to choose the most suitable modality, particularly where oncologic outcomes are equivocal.’ —Amalina Bakri, MD

To assess the feasibility of WAMs as an objective tool to measure upper limb function after breast and axillary surgery and compare between surgery types, Amalina Bakri, MD, and her colleagues gathered data on patients who wore Axivity (AX3) triaxial accelerometers at least 24 hours preoperatively and up to two weeks postoperatively. The WAM, which is worn on both wrists, measures upper limb activity in three planes. “The regain of function was seen through the increase of activity on the operated arm during the post-op period, with the greatest increase between day 1 and 2 and the recovery plateau on day 7,” said Dr. Bakri, a clinical research fellow in breast cancer surgery at Imperial College London, who presented the study at the 2021 virtual meeting of the American Society of Breast Surgeons. In essence, more surgery was associated with a greater decrease in activity from baseline. Patients who underwent axillary node dissection took longer to reach preoperative activity levels than those who had sentinel lymph node biopsies; the activity levels of patients who underwent deep inferior epigastric perforator decreased to 31% of preoperative levels before returning to 92% by day 13; and those who had a mastectomy experienced a decrease in preoperative activity level to 53% before returning to 78% by day 13. “Quantifying the morbidity of different treatments may help to track upper limb recovery and

help the clinician and patient to choose the most suitable modality, particularly where oncologic outcomes are equivocal,” Dr. Bakri said. “This information can be used to ensure optimization of patient outcomes by encouraging physical activity and keeping track of personalized activity goals, which could be integrated into the feedback-enabled personalized prehabilitation and rehabilitation care plan.” Dr. Bakri noted that her research is a feasibility study looking at the acute post-surgery recovery period. She and her colleagues plan to follow up with patients at three, six and nine months to gain a better understanding of how they recover from breast surgery and radiation. Dr. Avisar said the WAM seems promising and could be an exciting addition to the category of devices being used to track patients in other therapeutic areas, such as cardiac care, diabetes management and physical rehabilitation after knee and hip surgeries. “This is a concept I suspect we will see more of in the coming years,” Dr. Avisar said. He also thinks WAMs could be used in a proactive way to reduce the risk for lymphedema. “In general, we have not done much to prevent lymphedema except to do less surgery. We need to learn to refine the surgery and prevent the morbidity of some of these procedures,” Dr. Avisar said. “The WAM could help us monitor patients after surgery, because with early detection lymphedema is reversible and curable.” ■

IN THE NEWS

AUGUST 2021 / GENERAL SURGERY NEWS

2-Staged Nipple-Sparing Mastectomy May Reduce Complications By MONICA J. SMITH

rather novel two-staged approach to nipple-sparing mastectomy appears to reduce the risk for the most serious potential complications and may expand the procedure to patients who would have been high-risk candidates for NSM, according to new research. Although there is some controversy about how delayed procedures work, there is little question that they do; for more than 400 years, surgeons have created surgical wounds meant to stimulate the body to enhance blood flow to the wounded area. First described in breast surgery nearly 10 years ago, devascularization of the nipple-areolar complex (NAC) involves dividing the central portion of the breast skin envelope containing the NAC from the underlying breast tissue along the subcutaneous plane, and this is usually performed several weeks before NSM (Ann Surg Oncol 2012;19[10]:3171-3176). “This allows for compensatory increase in tissue blood flow prior to definitive NSM,” said Tammy Ju, MD, a breast surgical oncology fellow at Stanford University School of Medicine, in California. Under lead surgeon Irene Wapnir, MD, a breast surgical oncologist and professor of surgery at Stanford, breast surgeons at that institution perform the devascularization procedure by making radial or inframammary fold incisions through which the NAC and central breast skin envelope are separated from the underlying breast tissue. “The dissection is extended anywhere from 3 cm to 5 cm beyond the areolar edge. Essentially, you just detach the skin; it’s just like making the plane of a mastectomy flap,” Dr. Ju said. To evaluate the impact of devascularization of the NAC on ischemic outcomes—the most dreaded of which are skin-flap necrosis and nipple loss—Dr. Ju and her colleagues retrospectively reviewed data on patients who underwent either single- or two-stage operations at Stanford between 2015 and 2019. The single-stage cohort consisted of 67 patients and 103 breasts; the twostage group consisted of 60 patients and 109 breasts. The mean time between devascularization and NSM in the twostage group was 32 days, with 12 patients (17.4%) delaying NSM by 84 to 415 days for chemotherapy and locoregional radiotherapy, or due to indecision about their surgery. The same surgical oncologist performed the NSMs, and four plastic surgeons did the post-NSM reconstructions. Among the 103 breasts in the single-stage cohort, eight (7.8%) had nipple necrosis requiring operative excision;

this did not happen to any breasts in the two-stage cohort. In contrast, partialand full-skin thickness ischemic complications involving the part of the NAC or localized area of the mastectomy flap were similar between the two groups. Timing appeared to have some impact on the two-stage operation’s success in preventing ischemic complications. Five patients (nine breasts) underwent NSM less than 20 days after devascularization;

‘[The researchers] mainly use a vertical and radial-lateral incision, whereas we exclusively use inframammary incisions. I think any incision that stays away from the nipple—that is, inframammary versus vertical and radial—will have a better chance of avoiding nipple loss.’ —Katherine Yao, MD

continued on the following page

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IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2021

Better Surveillance for Serious HAIs By LEAH LAWRENCE

he CDC’s hospital-onset Adult Sepsis Event (HO-ASE) surveillance definition may do a better job at detecting serious hospital-associated infections (HAIs) than the criteria set by the Centers for Medicare & Medicaid Services (CMS). Many HAIs, including central line–associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus bacteremia and certain surgical site infections, are missed by CMS criteria, according to a retrospective analysis of 282,441 patients hospitalized from June 2015 to June 2018 at three hospitals. The analysis showed that almost twice as many patients met the HO-ASE criteria as had reportable HAIs (0.8% vs. 0.4%), and in-hospital mortality rates were more than twice as high for HO-ASEs (28.6% vs. 12.9%), according to Chanu Rhee, MD, MPH, a researcher at Harvard Medical School and Harvard Pilgrim Health Care Institute, and an infectious disease physician and associate hospital epidemiologist at Brigham and Women’s Hospital, in Boston (Clin Infect Dis 2021 Mar 29. doi:10.1093/cid/ciab217). Surveillance for HO-ASEs is relatively new and voluntary for hospitals, Dr. Rhee said. It stemmed from previous work that he and his colleagues did developing and validating a surveillance definition for sepsis based on objective clinical data that could be extracted from electronic health records. The ASE definition requires clinical indicators of treated infection (blood culture orders and antibiotics) and concurrent organ dysfunction (vasopressors, mechanical ventilation and abnormal laboratory values) and distinguishes hospital-onset from communityonset ASE based on when those criteria are met relative to a patient’s admission. “The HAIs that hospitals are required by CMS to publicly report are certainly important to track and prevent, but we knew that our current surveillance was likely missing many other important infections that occur in the hospital,” Dr. Rhee said. “About 10% to 20% of sepsis cases arise in-hospital and these tend to be very serious infections, and so we thought it would be interesting to look at the overlap between reportable HAIs and hospital-onset sepsis events.” The in-hospital mortality rate for HO-ASEs missed by reportable HAIs was twice as high as the mortality

Mastectomy continued from the previous page

55.6% of these breasts developed partialthickness NAC ischemic complications, compared with 11% in patients who delayed NSM 20 or more days. “Similarly, mastectomy flap ischemic events were higher for the short-interval group compared with the greater than 20-day group,” Dr. Ju said. There is a paucity of literature on twostage NSM and no code for it, but the results of this study have prompted Dr. Ju and her colleagues to offer two-stage NSM to a broader range of patients, such as those with more ptotic and larger

rates for reportable HAIs missed by HO-ASEs (28.1% vs. 6.3%). Of note, Dr. Rhee said reportable HAIs were only present in 14.5% of HO-ASEs, which indicates that the other 85.5% are caused by other serious events that are not captured routinely and reported, including hospital-acquired pneumonia, non–catheter-related bloodstream infections, intraabdominal infections, and skin and soft tissue infections. Jonathan Baghdadi, MD, PhD, of the University of Maryland School of Medicine, in Baltimore, who was not part of the study, said surveillance of HO-ASEs has value. “One important reason to have an objective measure of sepsis events is to facilitate comparison of outcomes among hospitals,” Dr. Baghdadi said. “This analysis demonstrates that the HO-ASE measure is sensitive to underlying differences in patient populations and may favor community hospitals over teaching hospitals or hospitals with large oncology practices.” Specifically, the study showed that incidence of HOASEs and reportable HAIs were higher in the academic hospital (Brigham and Women’s) compared with the two community hospitals, but mortality rates were similar. “We don’t think that means our academic hospital does worse when it comes to infection prevention,” Dr. Rhee said. “It is likely the different patient population we care for. For example, there are a larger number of oncology patients who, even with the best of care, are prone to developing serious infections when hospitalized.” Dr. Baghdadi said if the HO-ASE measure were to be used, it would likely require risk adjustment to account for differences in the patient populations served at different hospitals. Despite this value, Dr. Baghdadi said HO-ASEs should only be used to complement HAI surveillance. “It cannot and should not replace HAI surveillance,” he said, especially given the fact that only a small proportion of sepsis deaths are likely preventable. “I suspect that hospitals conducting HO-ASE surveillance would find that only a small proportion of events were actionable or led to identification of gaps in care.” Dr. Baghdadi referred to Dr. Rhee’s paper looking at sepsis-associated mortality in U.S. acute care hospitals that examined 568 randomly selected adults who died in the hospital or were discharged to hospice (JAMA Netw Open 2021 Feb 2. doi:10.1001/jamanetworkopen.2018.7571). Sepsis was the immediate cause of death in 34.9% of deaths; however, only 3.7% of sepsis-associated deaths were judged definitely or

breasts, and to advocate that they wait at least three weeks between operations. “We initially offered two-stage NSM to patients we thought were at higher risk for ischemic complications due to established risk factors. Even knowing those risks, patients who did not want to undergo two surgeries often preferred the single-stage approach; but now, based on our experience, they’re more comfortable waiting a few weeks between surgeries if it can decrease their risk of losing a nipple,” Dr. Ju said. Going forward, Dr. Ju and her colleagues intend to evaluate long-term outcomes and complications in the surgical delay group to further define ideal

On any given day, approximately one in 31 hospital patients has at least one HAI. moderately likely preventable with another 8.3% possibly preventable. Instead, Dr. Baghdadi said he viewed the purpose of monitoring for adult sepsis events to support performance improvement related to recognition and early management of sepsis—for example, shortening the time from order to administration of broad-spectrum antibiotics or providing bedside evaluation to clinically deteriorating patients. Dr. Rhee echoed this opinion, emphasizing that the preventability of these HO-ASE events is still unknown. “We still have to determine if they are mostly just happening in really sick patients, in whom these serious infections are sometimes inevitable,” Dr. Rhee said. “If so, that could defeat the purpose of ultimately increasing prevention and quality improvement programs to lower rates, incidence and mortality rates of these HAIs.” However, Dr. Rhee said he believes there is likely room to make progress in preventing HO-ASEs, but more research is needed. He also noted that HO-ASE surveillance can be fully automated, which eliminates the need for time-consuming and often subjective case reviews that are needed to identify reportable HAIs. “I don’t think sepsis surveillance would be a replacement for the current reportable HAIs, but I do think there is value in this,” he said. “They could be complementary in the sense that HO-ASEs could capture a lot of serious hospital-onset infections that are currently being missed and, potentially, identify new targets for prevention.” ■

candidates for the procedure. She presented the research as a poster at the 2021 annual meeting of the American Society of Breast Surgeons. Katherine Yao, MD, the chief of the Division of Surgical Oncology at NorthShore University HealthSystem, in Evanston, Ill., told General Surgery News that she and her colleagues do not offer two-stage NSM and would have to think about how this technique would improve outcomes or expand eligibility. As it stands, they do a high volume of NSM and rarely see nipple loss in their patients. In the technique Dr. Ju described, “they mainly use a vertical and radiallateral incision, whereas we exclusively

use inframammary incisions. I think any incision that stays away from the nipple—that is, inframammary versus vertical and radial—will have a better chance of avoiding nipple loss,” she said. Potential downsides to the two-staged approach include tumor subtypes where a delay before starting adjuvant therapy would be unwanted, and OR issues. “Scheduling two separate procedures is a real issue for us, and I imagine it would be for many surgeons,” Dr. Yao said. “So, I’m not sure we would adopt this technique at our institution. However, this technique may play a role for some patients. Success of NSM is really about patient selection.” ■

EXTENDED HERNIA COVERAGE 2021

August 2021

AHS Presidential Address

It’s Just a Hernia, Until It’s Not By DAVID CHEN, MD

Talking With Your Patients About Hernia Mesh By VICTORIA STERN

n 2013, Susan Eller felt a sudden pain in her groin. After months of physical exams and an exploratory procedure provided no answers, she finally identified the source: a femoral hernia. That May, Eller had her hernia repaired with polypropylene mesh. Her general surgeon said she’d be back on the tennis court in a few weeks. But instead, Eller’s groin pain intensified after her surgery. Over the next two years, she had a triple neurectomy, mesh removed and two tissue repairs after her hernias recurred. By 2015, still suffering from chronic pain, she needed an extensive abdominal wall reconstruction and had a large piece of polypropylene mesh placed across her midsection. That, Eller said, is when her problems became systemic: In addition to debilitating pain, she developed an itchy rash, irritable bowel syndrome and nausea. Over several months, she lost 40 pounds. In 2017, Eller flew to Los Angeles to see a hernia specialist with particular expertise in the female anatomy. continued on page 24 OPINION

The History of Inguinal Hernia Surgery

y surgeon friend asked me today ay if I preferred a day of straightforrward inguinal hernia repairs or a day of dealing with challenging disaster cases. s. I quickly responded that complicated ed patients are intrinsically easier because use the expectation levels all around are much more forgiving. An inguinal hernia repair is like a cholecystectomy—anything less than perfection is deemed a failure. That, and anatomy and probability dictate that if you operate enough, perfection is impossible. In the course of a year, I see approximately 250 patients who come to the Lichtenstein Amid Hernia Clinic at UCLA with complications of inguinal hernia repair—neuropathic pain, mesh pain, recurrence, fistula, infection. Invariably, one of the main questions asked is “Was anything done wrong?” This undercurrent has become more prevalent in this climate of mesh fear. While I have read thousands of operative reports and can predict suboptimal operative factors, I always remind patients that 1) surgeons operate with the intention of helping patients; 2) the patient before you and after you who had the same operation are likely doing fine; and 3) complications happen to every surgeon. What does surgical “science” tell us about optimal technique in inguinal hernia repair? Recurrence rates in the mesh era have dropped into the 2% to 3% range. Chronic pain rates, realistically, are over 5%, affecting patients’ quality of life. Minimally invasive laparoscopic and robotic techniques have matured to provide excellent outcomes with benefits of early recovery and lower rates of chronic pain. However, there is no one-size-fits-all in hernia, with many benefiting from a MIS [minimally invasive surgery] approach, some patients best served with an open Lichtenstein repair, others with a Shouldice tissue repair, and some with watchful waiting. Especially in hernia surgery, patient outcomes are most significantly tied to the surgeon—the one primary variable that

By EDWARD FELIX, MD, and TYLER ROUSE, MD

ne may wonder why they should read a review detailing the history of hernia repair. This is a question I asked myself when my chief, Professor Lloyd Nyhus, demanded it my of his residents. As a novice surgeon, I didn’t understand how learning the history of an operation could make me a better surgeon. But with time, I came to realize that by studying the history of a procedure, I would understand the principles that must be applied for success. Inguinal herniorrhaphy techniques have developed through the ages as knowledge of groin anatomy has improved. Through an appreciation of this evolution, modern approaches incorporating the lessons of the past have become safer and more effective. A failure to understand this history only results in repeating the mistakes of the past. The purpose of this review is to aid the modern hernia surgeon in the quest to perform a better inguinal hernia repair, no matter the choice of approach, whether it be open anterior or posterior, primary repair or mesh reinforced, laparoscopic or robotic. continued on the following page

continued on page 22

IN THIS ISSUE 14 Prophylactic Mesh: Have We Identified the Right Patient? Infection-Related Mesh Explantation Most Common in Ventral Hernia 16 Surgeons' Lounge: Component Separation For Abdominal Wall Reconstruction 18 Journal Watch: Recently Published Articles In Hernia Repair

OPINION

GENERAL SURGERY NEWS / AUGUST 2021

History of Inguinal Hernia Surgery continued from the previous page

Hernia and the Ancients The word “inguinal” derives from the Latin word for groin, “inguen,” and repair of a hernia has been called a herniorraphy. The etymology of the word “hernia” originates from the Greek word “hernios,” meaning an offshoot or bud, and the suffix “-rrhaphy” comes from the Greek word “rhaptein,” meaning to stitch or sew. Today, we use the term “hernioplasty” instead of herniorraphy because of the incorporation of a mesh patch into the repair. There is evidence of inguinal hernias dating back to the ancient Egyptians, Phoenicians and Greeks, who described hernias and ways of treating them. In the mummified remains of the pharaoh Merneptah (1215 b.c.e.), a large wound in the groin with the scrotum separated from the body may be evidence of the earliest attempt at hernia surgery. The writings of the Roman physician Celsus are some of the earliest accounts of the hernia and its repair, dating back to the first century c.e. His approach of closing the external ring was the best the medical world had to offer for nearly two millennia. Removal of the testicle became a routine part of the operation for centuries, as advocated by Galen. In Europe in the Middle Ages, French surgeon Guy de Chauliac (1298-1368) borrowed heavily from the writings of the famous Arabic surgeon, Albucasis, proposing six different treatments for inguinal hernia. His surgical textbooks became the standard for another 300 years.

Hernia Repair In the Renaissance The organized and detailed study of hernias began during the Renaissance, with the renowned French surgeon Ambroise Paré. In his book, “The Apologie and Treatise,” Paré provided a detailed account of the hernia operation, describing how the hernia contents should be reduced into the abdominal cavity and how the peritoneum should be sewn up. Surgical approaches, however, were limited by a lack of understanding of anatomy until the mid-1700s, sometimes called “the Age of Dissection,” or the Anatomic Era. Many famous surgeons made contributions to the understanding of hernias, including John Hunter, who in 1790 pointed out the congenital nature of some indirect hernias. English surgeon Sir Astley Cooper played a large role in the understanding and treatment of hernias. Not only did Cooper describe venous obstruction as the first step in the cascade of events in a strangulated hernia that leads to necrotic bowel, but it was his monograph in 1804 that had the largest impact. In it,

he described the fascia transversalis, and showed that it was the main barrier to herniation. He also showed its extension behind the inguinal ligament into the thigh as the femoral sheath and the pectineal part of the inguinal ligament, now known as Cooper’s ligament. Many others contributed to our understanding of groin anatomy, including Hasselbach, Camper, Scarpa, Richter and Gimbernat. Their names live on in anatomic components of the inguinal region. Several novel techniques were tried. William Wood, an English surgeon, took the hernia sac, folding it back on itself and using it as a sort of plug at the internal ring. The external ring would be sutured closed. A first assistant to Theodor Billroth in Vienna, Vincenz Von Czerny, simply tied off the hernia sac, and sutured closed the external ring without opening the canal—essentially the same operation as Celsus, from the first century. Unsurprisingly, these techniques did not stand up to scrutiny, with most patients experiencing a recurrence. In fact, like in ancient times, many surgeons in the 1800s left the wound open to close by secondary intention in the hope this scar would strengthen the repair. This was known as the McBurney operation, named after American surgeon Charles McBurney.

Hernia Repair Enters The Modern Era The big change came to inguinal hernia repair because of a collision of events. In 1867, surgeon Edoardo Bassini was stabbed with a bayonet while serving as a soldier in the war to unify Italy. While undergoing a prolonged recovery from his injuries, he studied anatomy at the University of Parvia. Armed with his new understanding of the importance of anatomy, Bassini traveled to train with the masters of the period: Theodor Billroth in Vienna, Bernhard Langerbeck in Berlin, and Joseph Lister in London. He became the director of surgical pathology at the University of Padua in 1882, and undertook detailed dissections of the groin region. With his newly acquired understanding of anatomy, Bassini developed the first modern approach to inguinal hernia repair. He devised a surgical method that involved dissection of the layers of the inguinal canal and then reconstruction of the posterior wall of the inguinal canal. By 1889, Bassini had operated on 274 hernias, and collected data on 216 patients over almost five years. He identified eight recurrences (a rate of 4%), 11 postoperative infections (5%), and no reported deaths among the 251 nonstrangulated repairs. To put that into contemporary perspective, the Billroth

A 15th-century gouache painting depicting Guy de Chauliac giving an anatomy lesson. Source: Wikimedia Commons

clinic at the time had a mortality rate of 6% and a recurrence rate of 33%. The study of anatomy continued to play an important role in the history of modern hernia repair. Chester McVay, while still a student at Northwestern University, in Chicago, published three seminal papers on the anatomy of the inguinal region with his teacher, the anatomist Dr. Barry Anson. In 1939, as an intern at the University of Michigan Hospital, McVay published a paper entitled “A Fundamental Error in the Bassini Operation for Direct Inguinal Hernia.” Although he went on to spend his entire career in a small town in South Dakota, McVay made a major contribution to improving the understanding of groin anatomy and altered Bassini’s repair accordingly. The repair he created has been called the Anson-McVay repair. In 1945, a Canadian surgeon, Earle Shouldice opened an outpatient hernia clinic applying the principles of the Bassini repair but further modifying it by adding an additional suture line to the reconstruction of the posterior wall. The results of his clinic were later published extensively by surgeon Robert Bendavid, establishing a new standard for recurrence, at 1%.

Mesh Reinforcement Although hernia repair based on anatomic principles was established following Bassini’s work, hernia recurrence and disability following repair remained problems. The concept of a reinforced repair was introduced to resolve these issues. The earliest attempts date back to Henry Orlando Marcy, a Boston surgeon, who recommended kangaroo tendon in 1887. It was not until Wallace Carothers, working for Dupont, discovered a

method for creating synthetic polymers in 1935, that led to Melick using nylon as a reinforcement. By the 1960s, Dr. Richard Newman had performed more than 1,600 inguinal hernia repairs using polypropylene. In 1968, in Los Angeles, Dr. Irving Lichtenstein first introduced the plug technique for femoral and recurrent inguinal hernia repair, using a rolled cylindrical or ‘cigarette’ Marlex mesh plug. This idea evolved to hand-rolling more of a cone shape, and even to preshaped mesh inserts. In 1987, Lichtenstein published a series of patients with repairs using Marlex mesh. This experience involved more than 6,000 patients followed from two to 14 years, with a recurrence rate of 0.7%. His technique became known as a “tension-free” repair and was popularized by Dr. Parvez Amid, who went on to modify and teach the approach. Using this new approach, inguinal hernia repair became an outpatient procedure that could be performed under local anesthesia. At approximately the same time, Dr. Arthur Gilbert developed a plug-and– patch, tension-free approach at his hernia clinic in Florida. Although extremely successful, the approach was later modified by Dr. Gilbert into the Prolene mesh system, which reinforced both sides of the floor. In New Jersey, Dr. Ira Rutkow, who studied Gilbert’s technique, popularized a version of the plug-and-patch and taught his method extensively. Both Gilbert’s and Rutkow’s repairs, along with Amid’s modifications of the Lichtenstein approach, remain the basis for most open inguinal hernia repairs performed today. The study of the anatomy of the groin led another group of surgeons to approach inguinal hernia repair in a totally new

EXTENDED HERNIA COVERAGE 2021 13

AUGUST 2021 / GENERAL SURGERY NEWS

direction—from a posterior approach. It goes back to 1876, when Annandale of Edinburgh presented his concept of a preperitoneal approach and then by Trait in 1891, who reported an intraperitoneal approach. Cheatle in 1921, and later Henry in 1936, proposed a posterior approach for inguinal and femoral hernias, but it wasn’t until the late 1950s that Lloyd Nyhus and his associates popularized a posterior approach for inguinal hernias, including direct ones. It was Algerian surgeon Rene Stoppa, who, in 1972, introduced the concept of an open posterior approach with a mesh prosthesis without fascial closure—the technique that became the basis of minimally invasive repairs. Dr. Raymond Read reported a mesh repair sutured in place with an opening for the cord structures in 1979, but because of failures through the slit made for the cord and at the sutured edges, Professor George Wantz began using a version of the Stoppa repair with a giant mesh covering the entire myopectineal orifice.

The Laparoscopic Approach In 1979, inguinal hernia repair was forever altered when South African surgeon, Ralph Ger, practicing in New York City, applied a posterior clip approach laparoscopically that he had previously performed in an open approach. His work was reported in the Annals of the Royal College of Surgeons of England in 1982 (64[5]:342344), but failed to gain a following until laparoscopy for general surgeons grew in popularity with the advent of laparoscopic cholecystectomy in 1989. Many surgeons worldwide then began to investigate how a laparoscopic approach based on previous posterior as well as anterior tension-free approaches could be performed. Some of the first were Dr. Leonard Schultz in Minnesota, with his plug-and-patch transabdominal laparoscopic approach, and Dr. Robert Fitzgibbons in Nebraska, as well as Dr. Morris Franklin in Texas, with their own intraperitoneal onlay mesh (IPOM) approaches. These techniques fell out of favor, however, due to complications with the plugs, the intraperitoneal mesh or recurrence because of failure to adhere to the principles previously established by the open posterior approach. Two different approaches, the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP), both emulating the open posterior approaches of Nyhus, Wantz and Stoppa, soon became the basis for today’s minimally invasive inguinal hernia repair. Surgeons working independently, including Drs. Ferzli, McKernan, Voeller, Payne, Arregui, Duncan and myself (Felix), as well as many others, became reluctant pioneers, developing techniques and instruments necessary to duplicate the concepts of the open posterior approach. In 2009, Dr. Jorge Daes, an accomplished laparoscopic

surgeon in Colombia, introduced E-TEP, which was a variation of the TEP procedure, allowing surgeons to apply the laparoscopic approach to patients in whom visualization is restricted because of limited space. The debate on whether the TAPP, TEP or E-TEP approach is best; whether fixation is necessary; or what mesh should be used began, and has continued until today. What became apparent from all the different surgeons and slightly different techniques, however, was that there are certain underlying principles, steps or rules that should be followed

for the minimally invasive repair to have both short- and long-term success. These concepts were published in the Annals of Surgery, 25 years after the first successful laparoscopic repairs were reported (Ann Surg 2017;266[1]:e1-e2).

Robotic Hernia Repair In 1999, the first robotic TAPP (R-TAPP) inguinal hernia repair was performed in Europe by Dr. Jacques Himpens, and in the United States by Dr. Barry Gardiner. Most of the early R-TAPP procedures, however, were reported in conjunction with robotic prostatectomy. By

2015, reports of stand-alone R-TAPP were published. On the International Hernia Collaboration (IHC), a social media platform for hernia surgeons established in 2012, the growth of robotic inguinal hernia repair was stimulated through video education and collaboration. Pioneers of the robotic approach, like Dr. Conrad Ballecer from Arizona, presented their techniques and were critiqued by surgeons who had extensive experience with the laparoscopic approach. The techniques used to perform R-TAPP soon came to mimic those of laparoscopic TAPP, and continued on page 15

IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2021

Prophylactic Mesh: Have We Identified the Right Patient? By MONICA J. SMITH

s research supporting the use of prophylactic mesh to prevent incisional hernia continues to grow, the focus of managing that surgical complication may change from treatment to prevention. The key to shifting this pendulum is identifying the right patients. Are we there yet? “I will caveat the answer with ‘we’re working on it and we’re close,’” said William Hope, MD, the program director of the general surgery residency program at the Novant/New Hanover Regional Medical Center, in Wilmington, N.C., speaking at the 2021 virtual Abdominal Wall Reconstruction Conference. When the European Hernia Society (EHS) published its recommendation on prophylactic mesh augmentation (PMA) in 2015 (the latest to date), there weren’t enough data from sufficiently large trials for the society to strongly support the use of PMA in all patients meeting the criteria for particular risk groups. Since then, things have changed. A year later, researchers led by Filip Muysoms, MD, in Belgium reported the findings of a randomized controlled trial of 120 patients with abdominal aortic aneurysms. At two years’ followup, the incisional hernia rate in patients who underwent primary suturing was

28%, while none of the patients with a PMA (recto-rectus, large-pore PPE) developed an incisional hernia (Ann Surg 2016;263[4]:638-645). “This is probably the easiest high-risk group to identify, and I think we would all agree on PMA in patients with abdominal aortic aneurysms,” Dr. Hope said. This was followed by the PRIMA trial, which included two groups of high-risk patients—those with abdominal aortic aneurysms and those with obesity (body mass index ≥27 kg/ m2)—as well as two mesh placement techniques, onlay and sublay (Lancet 2017;390[10094]:567-576). “They reported that you definitely decrease the chance of an incisional hernia by placing a mesh. This was really the first time this was shown with an onlay, and at least in prophylaxis, the onlay did as well as the sublay,” Dr. Hope said. Mesh has also been investigated in the setting of parastomal hernia prevention. In 2018, the EHS recommended use of prophylactic synthetic nonabsorbable mesh on construction of the end colostomy. “This was a strong recommendation based on a lot of data,” Dr. Hope said. A follow-up systematic review and meta-analysis that found PMA reduced the risk for incisional hernia after stoma reversal further supported the EHS’s recommendation (Hernia

2019;23[4]:733-741). Still, among the surgical interventions aimed at preventing incisional hernia (e.g., using minimally invasive techniques, minimizing potential wound complications and using optimal suturing techniques), PMA is the most controversial: placing mesh to prevent an outcome that hasn’t happened. “The risk‒benefit has to be carefully considered and balanced,” John Fischer, MD, told General Surgery News. “It’s similar to the dilemma we face in hernia repair: We know there’s a risk of recurrence if we don’t use mesh to support the repair, but we’re also putting mesh into patients who won’t develop a recurrence.” Another reason PMA is controversial is that much of the data supporting its

use come from European trials, and it’s not certain that the findings of those trials are applicable to patients in the United States. “The PRIMA trial shows a nice benefit to using mesh, but those patients really aren’t the same as the patients we see. We had the same issue with the STITCH trial, which showed the benefit of closing with very small bites and lots of suture: Is it generalizable?” said Dr. Fischer, an associate professor of surgery at the University of Pennsylvania, in Philadelphia. Also worth noting is that no mesh has been indicated for use as a prophylactic against incisional hernia. “So it’s really an off-label use. You’d be using your own clinical judgment,” Dr. Fischer said.

‘The risk–benefit has to be carefully considered and balanced. It’s similar to the dilemma we face in hernia repair: We know there’s a risk of recurrence if we don’t use mesh to support the repair, but we’re also putting mesh into patients who won’t develop a recurrence.’ —John Fischer, MD

Infection-Related Mesh Explantation Most Common in Ventral Hernia By ETHAN COVEY

ates of mesh explantation due to infection following hernia surgery, while low, are highest among patients receiving ventral hernia repair, according to findings from a recently published study. The report reinforces the importance of optimizing surgical approaches and working to eliminate surgical site infections (SSIs) because outcome rates varied according to the type of hernia operation, baseline patient characteristics and effectiveness in preventing infection (J Am Coll Surg 2021;232:872e881). “This is the largest study on mesh infection, conducted in over 100,000 patients over five years with a lot of interesting findings,” said study author Kamal M. F. Itani, MD, the chief of surgery at the VA Boston Health Care System. “Unlike others in the literature, this study looks at ventral, umbilical and inguinal hernias, and gives specifics about each operation.” Dr. Itani and his colleagues conducted the retrospective study using data from

the Veterans Affairs Surgical Quality Improvement Program, as well as chart reviews of veterans who underwent abdominal or groin hernia repair that included synthetic mesh implantation, during 2008-2015.

‘Despite the devastating effect of mesh infection, the risk of recurrence outweighs the risk of infection. By driving the risk of infection lower, we can further decrease the risk–benefit ratio of placing a mesh.’ —Kamal M. F. Itani, MD The primary outcome of the study was to identify how often mesh explantation, caused by infection, occurred within five years following surgery. SSIs were defined as the presence of VA Surgical Quality Improvement Program‒reviewed superficial, deep incisional or organ/ space SSIs within 30 days of the index operation.

A total of 103,869 hernia operations were tracked, of which 74.3% were inguinal, 10.7% were umbilical and 15.0% were ventral. While the incidence of mesh explantation due to infection was low, occurring in 0.3% of the patients, rates were highest among patients who underwent ventral repair (1.5%), followed by those in the umbilical (0.6%) and inguinal (0.1%) groups. Similarly, SSIs were rare yet placed the patient at a higher risk for mesh explantation. Among patients with SSIs, mesh removal occurred in 29.2% of those with deep wound infections, 22.4% with organ/ space SSIs and 6.4% with superficial SSI. Staphylococcus aureus was the most common causative organism in SSIs. While SSIs occurred within the first 30 days after the procedure, mesh explantation did not take place until a median of 208 days from the index hernia surgery. “This means that surgeons are attempting various maneuvers at salvaging the mesh over a period of seven months,” Dr. Itani noted. “We are very interested in looking at what happens between

index hernia operation and mesh explantation, what measures surgeons are taking to salvage the mesh and how often they are successful.” The researchers found that many factors influenced whether a patient was more likely to require mesh explantation. These included obesity (odds ratio [OR], 1.7), longer operations (OR, 1.83), and contaminated wound sites (OR, 2.27). Additionally, open surgery was more likely to lead to explantation than were laparoscopic procedures. “Most hernia surgeries are elective and patients’ conditions should be optimized prior to undertaking these operations,” Dr. Itani said. “All measures of SSI prevention should be strictly observed to prevent a postoperative SSI.” Yet, he stressed that although the risks for SSIs and related mesh explantation are real, they shouldn’t cloud understanding of the benefits of mesh usage. “The standard of care in elective hernia surgery calls for the placement of a mesh,” Dr. Itani said. “The risk of hernia recurrence is much higher without a mesh. Despite the devastating effect of

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But researchers are homing in on risk stratification and patient identification tools that could eventually render PMA much less controversial. Five years ago, Dr. Fischer and his colleagues showed that a preoperative risk assessment could be used to predict which patients were more likely to develop an incisional hernia (Ann Surg 2016;263[5]:1010-1017). “There are clearly high-risk patients who will develop hernias at a higher rate and sooner than others, and I think this was the first step into trying to figure out the patient populations this could happen to,” Dr. Hope said. More recently, Dr. Fischer and his colleagues identified procedure-specific risk factors and developed an algorithm that can be used at the point of care to predict which patients might develop an incisional hernia (Ann Surg 2019;270[3]:544-553). “Ultimately, this led to the Penn Hernia Risk Calculator, which is an app you can download to your smartphone and enter patient characteristics. This is something we can use quickly and easily in discussions with our patients about risk strategy and risk stratification, and I think it will go a long way to help surgeons,” Dr. Hope said. “I’m not sure there will ever be a universal definition of what is high risk, but the calculator and support tools that are coming as we gain more information about risk factors are going to be really helpful,” he said. ■

Hernia History continued from page 13

reported outcomes were similar. The robotic approach, however, allowed more surgeons to adopt a minimally invasive approach, and many applied it to situations that were extremely difficult for conventional laparoscopy—such as post‒radical prostatectomy, mesh removal and giant scrotal hernias. Inguinal hernia repair has come a long way from amputation to reconstruction and from large open incisions to minimally invasive approaches

assisted by robots. What has been constant through this evolution is that the repairs need to be based on anatomic considerations and that certain principles need to be applied. When we look closely at the history of inguinal hernia repair just presented, we find that the steps taken to perfect the current minimally invasive repairs duplicate those taken by surgeons who developed open approaches. It is my hope that surgeons will continue to study the past to guide their efforts to advance the safety and efficacy of repairs they presently perform and

ones they may develop in the future. A failure to understand our history will result in repeating the mistakes of the past. We do not need to rediscover the wheel, but rather improve upon it. ■ —Dr. Felix is a general surgeon from Pismo Beach, Calif., and a member of the editorial advisory board of General Surgery News. Dr. Rouse is associate anatomical pathologist, Huron Perth Healthcare Alliance, Stratford, Ontario, and adjunct professor, Department of Pathology and Lab Medicine, Western University, London, Ontario, Canada.

mesh infection, the risk of recurrence outweighs the risk of infection. By driving the risk of infection lower, we can further decrease the risk‒benefit ratio of placing a mesh.” According to William J. O’Brien, MS, of the Center for Healthcare Organization and Implementation Research at the VA Boston Healthcare System, who was a co-author of the study, the research also highlights the importance of such large, detailed looks at surgical risk factors. “This study speaks to the importance of having a validated, high-quality surgical registry that allows us to study postoperative complications that are infrequent yet have severe consequences for the patient’s long-term health,” Mr. O’Brien said. “The VHA is one of the few institutions where researchers can not only identify a large national surgical population, but also combine rich clinical data to understand what is happening with these patients over a long follow-up ■ period.” This work was supported by an investigator-initiated award from Pfizer.

" ! ! !

GENERAL SURGERY NEWS / AUGUST 2021

Component Separation for Abdominal Wall Reconstruction

Welcome to the August issue of The Surgeons’ Lounge. In this issue, Lisandro Montorfano, MD, the chief general surgery resident at Cleveland Clinic Florida, in Weston, interviews Andres Mascaro Pankova, MD, from the Department of Plastic and Reconstructive Surgery at Cleveland Clinic Florida, about component separation for abdominal wall reconstruction. Dr. Pankova provides up-to-date responses to the most common questions regarding component separation for abdominal wall reconstruction. Also in this issue, another installment of “The Instrument, the Name” features the Titan CSR (Cestero Surgical Retractor; ASR Systems, Inc.; www.asrsystemsinc. com). We look forward to our readers’ questions, comments and interesting cases to present. Sincerely, ly, Samuel Szomstein, MD, FACS CS Editor, The Surgeons’ Lounge nge Szomsts@ccf.org

In some cases, it is not possible to approximate the abdominal muscle wall edges, and in these cases mesh is almost always mandatory as a bridge to achieve abdominal wall integrity. —Andres Mascaro Pankova, MD

Dr. Montorfano: What is component separation? to approximate both edges of the muscle. In What are the different techniques of component some cases, it is not possible to approximate separation for abdominal wall reconstruction? the abdominal muscle wall edges, and in these Dr. Pankova: Component separation involves cases mesh is almost mandatory as a bridge to Lisandro separating and advancing certain layers of the Montorfano, MD achieve abdominal wall integrity. abdominal wall muscle, lengthening them so that the Selection of mesh for ventral hernia repair muscles on the right and left sides can be brought and abdominal wall reconstruction can be chalcloser to the midline for sufficient closure. This techlenging. Since the adoption of a tension-free nique restores the structural and functional integrimesh repair, the recurrence rates and outcomes ty of the abdominal wall and aids in the aesthetic after ventral hernia repair have substantialappearance. Depending on the muscle(s) divided, ly improved. In cases where the field is conthe classic techniques of component separation can taminated, a biologic acellular dermal matrix be broadly categorized into anterior and posterior. (ADM) mesh is the recommended option. If Andres Mascaro Anterior component separation divides the external the field is clean and uncontaminated, a synPankova, MD oblique muscle lateral to the linea semilunaris and thetic nonabsorbable mesh can be used. separates the external oblique from the underlying internal oblique muscle. This can be approached via open Dr. Montorfano: What is your opinion about or minimally invasive techniques. Minimally invasive tech- onabotulinumtoxinA (Botox, Allergan Aesthetics) to niques are performed by making a small incision at the level allow muscles of the abdominal wall to reapproximate? of the linea semilunaris and dividing the external oblique fasDr. Pankova: Recently, botulinum toxin A (BTA) has cia with raised skin flaps. arisen as a potential tool in the surgeon’s armamentarium for The posterior component separation occurs just medi- abdominal wall reconstruction. Treatment of a muscle with al to the linea semilunaris, and the transversus abdominis is BTA results in functional denervation within two days with released by dividing the fascia and muscle insertion to the peak effect after four to six weeks, leading to muscle atroposterior layer. This allows a wide plane of preperitoneal dis- phy and paresis. The broad range of indications for BTA has section and advancement. raised the potential for its use in abdominal wall reconstrucSimilar to the anterior component separation, a poste- tion. The application of BTA for this purpose is considered rior component separation is undertaken using the same off-label by the FDA. There are promising data regarding approaches. the use of BTA. BTA appears to be a safe and useful adjunct to achieve primary fascial closure in complex abdominal wall Dr. Montorfano: How does component separation apply reconstruction with loss of domain. By reversibly inducing to abdominal wall hernia repair? What are the indications flaccid paralysis of the lateral abdominal wall, BTA allows for for component separation? closer apposition of the midline fascia, reducing tension on Dr. Pankova: Complex abdominal wall hernias are more the repair and decreasing intraabdominal pressure, both sigdifficult to repair and often have a higher rate of recurrence nificant risk factors for recurrence. and postoperative complications. To repair these complex and sometimes recurrent hernias, component separation is Dr. Montorfano: Could you mention some new plastic usually one of the techniques of choice. It is particularly use- and reconstructive surgery advances in abdominal wall ful when there is loss of domain, and a conventional primary reconstruction? hernia repair cannot be performed. The advantage is basicalDr. Pankova: The evolution and success of intestily the ability of completely reestablishing the abdominal wall nal and multivisceral transplantation over the past 20 years integrity in a dynamic fashion using native tissue. The dis- has raised the issue of difficult, or even impossible, abdomadvantages are the possible surgical complications associat- inal closure. Abdominal wall transplant is a type of comed with these types of procedures. When a component of the posite tissue allograft that can be utilized to reconstitute abdominal wall is released, the area may potentially become the abdominal domains of patients who undergo intesweakened, and the patient may develop a bulge or another tinal transplantation, and the results are encouraging. hernia in the location in the future. This is a complex procedure that requires microsurgical techniques and immunosuppressive drugs after surgery. Dr. Montorfano: Is patient selection important at the It is being developed and may become an option in the near time of performing a component separation? Who is the future for large complex abdominal wall defects. ■ ideal candidate for component separation techniques? Dr. Pankova: Yes, absolutely. The ideal candidate is a Suggested Reading patient who does not smoke, has a normal body mass index Albright E, Diaz D, Davenport D, et al. The component separaand no previous abdominal wall radiation. Unfortunately, tion technique for hernia repair: a comparison of open and endothis is not always possible. More important is the integrity of scopic techniques. Am Surg. 2011;77(7):839-843. the abdominal wall. Previous surgeries may potentially com- Levi DM, Tzakis AG, Kato T, et al. Transplantation of the promise the integrity of the rectus and lateral muscles and, abdominal wall. Lancet. 2003;361(9376):2173-2176. as such, the ability of performing a component separation. Pauli EM, Rosen MJ. Open ventral hernia repair with component separation. Surg Clin North Am. 2013;93(5):1111-1133.

Dr. Montorfano: Do patients undergoing component separation need mesh reinforcement? If so, what type of mesh can be used for this purpose? Dr. Pankova: There are data to support that use of mesh in association with muscle release and flap advancement has a lower rate of hernia recurrence, even when it is possible

Sailes FC, Walls J, Guelig D, et al. Synthetic and biological mesh in component separation: a 10-year single institution review. Ann Plast Surg. 2010;64(5):696-698. Weissler JM, Lanni MA, Tecce MG, et al. Chemical component separation: a systematic review and meta-analysis of botulinum toxin for management of ventral hernia. J Plast Surg Hand Surg. 2017;51(5):366-374.

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The Instrument, the Name

The TITAN CSR™ (Cestero Surgical Retractor) By Bora Kahramangil, MD (PGY-4), and Lisandro Montorfano, MD (chief resident), Cleveland Clinic Florida, in Weston new retractor is especially promising The TITAN CSR has rauma surgery is uniquely uely for trauma surgeons in both civilian been formally deterpositioned among gennbe and military practices, there is also mined to be a Class eral surgical specialties, as s potential benefit for other surgical I, 510(k)-exempt surgeons routinely have Figure 1. specialties that routinely perform lapamedical device to operate on patients m The TITAN CSR. rotomies, such as general surgery, by the FDA, and in extremis. This is furb colorectal surgery, surgical oncology, is in clinical use at ther compounded by the vascular surgery, transplant surgery University Hospital in limited resources in combat bat Univ Figure 2. The TITAN CSR achieving and hepatobiliary surgery. San Antonio. Although this trauma surgery. When perrAn exposure of abdominal structures. forming a damage controll laparotomy, there are only two goals: to achieve hemostasis and control contamination. The time in the OR must be limited to the absolute minimum necessary to achieve these goals. Following damage control, the patient must be expeditiously transferred to the ICU for continued resuscitation, or to a trauma center in combat settings. Due to the time-sensitive nature of trauma surgery, table-mounted retractors with long setup times are rarely appropriate for use in the trauma patient population. An ideal trauma retractor would be a multiarm self-retaining retractor, which does not require any table mounting. The TITAN CSR (ASR Systems, Inc.; www.asrsystemsinc.com) was designed by Ramon Cestero, MD, with this principle in mind. This retractor has four intraabdominal blades with two blades retracting on each side of the midline abdominal incision (Figure 1). Modular arms expand laterally on this four-blade frame with the resulting retraction, both establishing the lateral separation of the abdominal wall and stabilizing the retractor in place. The four-blade configuration forms a stable base to prevent unintended rotations. Additional blades can be attached onto the modular arms to expose deep abdominal structures. The ring attachments are compatible with the Bookwalter (Symmetry Surgical) blades, facilitating adoption of the TITAN CSR in hospitals already using the Bookwalter retractor, with minimal added cost. Furthermore, the TITAN CSR ring height is adjustable, and the four-blade frame can be adapted to different incision lengths ranging from For more information or to place an order, please contact: Indications United States, Canada, Asia, Pacific, Latin America SurgiMend is intended for implantation to reinforce soft tissue where weakness 13 to 37 cm, allowing the use of this USA 877-444-1122 866-800-7742 fax exists and for the surgical repair of damaged or ruptured soft tissue membranes. retractor in patients with different International +1 617-268-1616 + 1 617-268-3282 fax surgimendsales@integralife.com SurgiMend is specifically indicated for: types of body habitus. Visit us at: SurgiMend.com • Plastic and reconstructive surgery. In cadaveric studies, the TITAN • Muscle flap reinforcement. • Hernia repair including abdominal, inguinal, femoral, diaphragmatic, scrotal, SurgiMend, Integra and the Integra logo are registered trademarks of Integra LifeSciences CSR was found to achieve excellent umbilical, and incisional hernias. Corporation or its subsidiaries in the United States and/or other countries. exposure of the abdominal structures ©2018 Integra LifeSciences Corporation. All rights reserved. 1035834-2-EN comparable to the table-mounted systems (Figure 2). Furthermore, it was noted to have a faster setup time due to its non–table-mounted design.

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GENERAL SURGERY NEWS / AUGUST 2021

For Your Practice: Recent Articles in Hernia Repair n this installment of Journal Watch, we look at recently published articles dealing with a subject near and dear to my heart: hernia repair. As part of the practice of most general surgeons, I hope readers will find these articles on hernia management worthwhile, relevant, and useful to change, question or reinforce current practice. We’ll look at a recent meta-analysis on mesh use in laparoscopic inguinal hernia repair, the effect of immunosuppression and/or corticosteroids on inguinal hernia repair outcomes, and we’ll also take a look at two articles, with differing conclusions, on negative pressure wound therapy after open ventral hernia repair.

Lightweight Mesh Provides No Benefit Over Heavyweight Mesh in Lap Inguinal Hernia Repair In Annals of Surgery, Bakker and colleagues published further guidance on mesh use for minimally invasive hernia repair (2021;273[5]:890-899). The researchers used both meta-analysis and trial sequential analysis (TSA) of randomized controlled trials that compared outcomes of heavyweight and lightweight mesh. For this study, the authors defined lightweight mesh as less than 50 g/m2 and heavyweight mesh as greater than 70 g/m.2 Included trials compared the different weights of mesh in laparoscopic inguinal hernia repair cases for reducible inguinal hernias using the same surgical technique and fixation method, with at least three-month follow-up. Outcomes measured included postoperative pain and hernia recurrence. TSA was performed to determine whether sufficient data were available within the randomized controlled trials to provide a reliable conclusion. A total of 12 trials were analyzed for 2,909 patients (1,490 with lightweight and 1,419 heavyweight mesh), with follow-up ranging from three to 60 months. Eight studies reported postoperative pain outcomes. Although there was no statistical difference in risk for any pain (123/1,362 patients with lightweight mesh vs. 127/1,277 with heavyweight mesh; relative risk [RR], 0.79; 95% CI, 0.52-1.20) or severe pain (3/1,226 with lightweight vs. 9/1,079 patients with heavyweight mesh; RR, 0.38; 95% CI, 0.11-1.35), TSA showed insufficient data were available to reach a reliable conclusion. Further permutations of analysis were performed based on variables such as recurrence and pain score cutoffs. Eleven studies reported hernia recurrence outcomes. There was a statistically significant increased risk for recurrence with lightweight mesh repairs (32/1,571 vs. 13/1,508 patients with heavyweight mesh; RR, 2.21; 95% CI, 1.14-4.31), which appeared reliable after TSA. Subanalyses continued to show increased risk for recurrence with the lightweight mesh for direct inguinal hernia repair (19/500 patients vs. 6/511 with heavyweight mesh; RR, 2.31; 95% CI, 0.83-6.43), indirect repair (12/866 vs. 6/842, respectively; RR, 1.66; 95% CI, 0.664.18), and laparoscopic repair when fixation was used (10/942 vs. 7/866, respectively; RR, 1.20; 95% CI, 0.403.61). However, TSA revealed insufficient data for these subanalyses. The authors should be lauded for their updated review from the last Cochrane review by Sajid et al in 2013 (Cochrane Database Syst Rev 2013;2:1-50) evaluating outcomes after inguinal hernia repair based on mesh weight. Of note, this study included one of the most recent large randomized controlled trials from Roos et al (Ann Surg 2018;268[2]:241-246). Through TSA, it is evident that high variability within studies still makes it difficult to discern which mesh weight is superior

for postoperative pain. However, there does seem to be strong evidence that lightweight mesh has no advantage, and often poorer outcomes, in regard to hernia recurrence compared with heavyweight mesh. Limitations of this study are those inherent within systematic reviews, but the authors attempt to verify with TSA. Variations in surgical technique and specific mesh types within each randomized controlled trial may make these results difficult to apply to a specific clinical practice. The results, however, are quite strong to demonstrate that lightweight mesh may not provide any superior outcomes to heavyweight mesh, and instead only affect cost of the overall procedure.

Immunosuppression and/or Preoperative Corticosteroids Do Not Increase Wound Complications After Inguinal Hernia Repair In Surgical Endoscopy, Varga and colleagues published their analysis on the effect of immunosuppression and preoperative corticosteroid use on patients undergoing inguinal hernia repair (2021;35[6]:2953-2964).

Using the Herniamed Registry (private practice surgeons from Germany, Austria and Switzerland), the authors identified patients aged 16 years or older who received an initial unilateral inguinal hernia repair with approved surgical techniques and mesh, with one-year follow-up. Matched groups were then delineated by patients with and without immunosuppressive conditions and/or corticosteroid treatments before repair. Matching criteria are further described in the study, but included body mass index, defect size, preoperative pain and operative method. Primary outcomes evaluated included perioperative complications, reoperations within 30 days related to complications, recurrence at one year, pain on exertion,

Arielle Perez, MD, MPH, MS Director of UNC Health Hernia Center and Assistant Professor of Surgery in the Division of General, Acute Care, and Trauma Surgery at the University of North Carolina at Chapel Hill School of Medicine —Column Editor

pain at rest and chronic pain requiring treatment after one year. Secondary outcomes evaluated included rates of bleeding, seroma, surgical site infections (SSIs), bowel injury and ileus. Of note, 142,488 patients met the inclusion criteria for matching, with 2,312 (1.6%) identified with immunosuppressive conditions and/or corticosteroid treatments before surgery. More than half of these patients (1,225) had an open repair; 44% (1,010) had a laparoscopic repair and 2.7% (62) had other techniques. Appropriate patients without immunosuppressive conditions and/or corticosteroid treatments before surgery were identified, and 2,297 propensity-scored pairings were formed for analysis. Propensity score matching analysis of the pairs revealed no effect on primary or secondary outcomes due to immunosuppressive conditions and/or corticosteroid treatments. Subanalysis of patients with only immunosuppressive conditions, only corticosteroid treatments or both revealed no significant difference in outcomes. The authors provide information on the effect of immunosuppressive conditions and/or corticosteroid treatments on postoperative outcomes after initial unilateral inguinal hernia repair. Despite evidence that immunosuppression and corticosteroids can hinder wound healings, the authors’ findings are similar to results from the study by Haskins et al that looked at immunosuppression with ventral hernia repair outcomes, with the notable exception of the difference in seroma rate for inguinal hernia repair (Surgery 2018;164[3]:594-600). Limitations of this study include evaluation of the broad category of inguinal hernia repair rather than specific surgical techniques; generalized evaluation of the immunosuppressed state and corticosteroid use rather than specifics of disease type and/or specific drug and dose; and those limitations inherent in any registry, such as missing and/or incorrect data collection. The authors acknowledge the higher-than-normal postoperative complication rate, but attribute this to the distribution of surgical methods. Nevertheless, their study provides further evidence that hernia repair can be performed safely in most patients with immunosuppressive conditions and/or corticosteroid treatments.

RCT Shows Reduction of SSO and SSI With Negative Pressure Wound Therapy in Open Ventral Hernia Repairs In Annals of Surgery, Beuno-Lledó and colleagues published the results of a single-center randomized controlled trial evaluating the effects of negative pressure wound therapy (NPWT) on closed incisions after ventral incisional hernia repair (VIHR) (2021;273[6]:1081-1086).

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In the study, all adult patients undergoing elective midline VIHR with a defect width of at least 4 cm were eligible. Exclusion criteria included patients with abdominal surgery performed within 30 days, emergency VIHR, cirrhosis and pregnancy. Surgeries were performed by five surgeons; preoperative antibiotics, chlorohexidine prep, mesh use, fascial closure and drain placement were standardized to reduce variability. VIHR consisted of retrorectus repair, transversus abdominis repair or anterior component separation (ACS). Patients were randomized 1:1 to either the intervention group for seven days of NPWT with the PICO system (Smith and Nephew) at –80 mm Hg or normal sterile dressing. The primary outcome was development of a surgical site occurrence (SSO) within 30 days of VIHR. The secondary outcome was hospital length of stay (LOS). The study was powered to see a reduction from 30% to 10% SSOs in the treatment group, requiring a sample size of 150 patients. A total of 150 patients were recruited with 146 analyzed (72 having NPWT and 74 controls). There were no statistically significant differences in baseline or hernia characteristics. Wound class was not provided. There was a statistically significant difference in SSOs (13.6% vs. 29.8%; P=0.042) with an even more impressive

difference in SSIs (0% vs. 8%; P=0.002). All six SSIs were superficial and treated with oral antibiotics, all in the control group: five after ACS and one after retrorectus repair. There was no statistical difference in hospital LOS, seroma, hematoma or dehiscence. Univariate analysis demonstrated a BMI greater than 30 kg/m2 and ACS repair to be predictive of SSIs after surgery. The authors should be commended on undertaking a randomized controlled trial of this magnitude. Their results provide further information on the utility of NPWT after laparotomy, specifically VIHR. Although the study was well protocolized, the spectrum of repair methods with various mesh types makes it difficult to apply the results of the study to all VIHRs. NPWT reduced SSO rates after VIHR, but it is unclear whether it is specific to ACS repair; the study was not powered to draw this conclusion. Postoperative management was not well described, and likely did not include an enhanced recovery after surgery (ERAS) pathway. Of interest, LOS was longer than what has been reported in other studies, such as that from Sartori (Hernia 2021;25[2]:501-521), both with and without ERAS pathways. The authors noted that the absolute cost of NPWT is six times more than standard dressings, but may be offset by LOS, required subsequent procedures and

wound care. However, a cost–benefit analysis was not performed to provide further information on its utility. Only one type of NPWT system was used, such that results may not be applicable to other systems. Drain use may have contributed to no differences seen in seroma and hematoma formation. With prior analysis of the American College of Surgeons National Surgical Quality Improvement Program published by Jolissaint demonstrating that 25% of ventral hernia repair patients will have a recurrence within five years, with the risk doubling for those with an SSO (Surgery 2020;167[4]:765771), results of Bueno-Lledó’s study may provide further support for NPWT use in certain clinical situations. Monitoring of individual surgical practices can provide further guidance on applicability and benefit.

Single-Surgeon Study Shows No Effect of NPWT on Rates of SSO and SSI in Open Ventral Hernia Repair In Hernia, Seaman and colleagues published the results of NPWT on ventral hernia repair from a single center by a single surgeon (2021 May 19. Epub ahead of print). continued on the following page

Table. Summary of Four Studies Discussed Journal Article

Key Takeaways

Words of Caution When Reading

Useful Related Articles

Heavyweight mesh is superior to lightweight mesh in laparo-endoscopic inguinal hernia repair: a meta-analysis and trial sequential analysis of randomized controlled trials. Bakker WJ, Aufenacker TJ, Boschman JS, et al. Ann Surg. 2021;273(5):890-899.

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No difference in postoperative pain with mesh weight after laparoscopic inguinal hernia repair.

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Sajid MS, Leaver C, Sains P, et al. Lightweight versus heavyweight mesh for laparoscopic repair of inguinal hernia. Cochrane Database Syst Rev. 2013;2:1-50.

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Lightweight mesh has no advantage, and often poorer outcomes, compared with heavyweight mesh in regard to hernia recurrence after • laparoscopic inguinal hernia repair.

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Roos M, Bakker WJ, Schouten N, et al. Higher recurrence rate after endoscopic totally extraperitoneal (TEP) inguinal hernia repair with ultrapro lightweight mesh: 5-year results of a randomized controlled trial (TULPtrial). Ann Surg. 2018;268(2):241-246.

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Achelrod D, Stargardt T. Cost-utility analysis comparing heavy-weight and light-weight mesh in laparoscopic surgery for unilateral inguinal hernias. Appl Health Econ Health Policy. 2014;12(4):151-163.

Are immunosuppressive conditions and preoperative corticosteroid treatment risk factors in inguinal hernia repair? Varga M, Köckerling F, Mayer F, et al. Surg Endosc. 2021;35(6):2953-2964.

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Immunosuppressive conditions and/ or corticosteroid treatments had no statistically significant effect on primary or secondary outcomes.

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Subanalysis on patients with only immunosuppressive conditions, only corticosteroid treatments and both revealed no significant differences in outcomes.

Haskins IN, Krpata DM, Prabhu AS, et al. Immunosuppression is not a risk factor for 30-day wound events or additional 30-day morbidity or mortality after open ventral hernia repair: an analysis of the Americas Hernia Society Quality Collaborative. Surgery. 2018;164(3):594-600.

Prophylactic single-use negative pressure dressing in closed surgical wounds after incisional hernia repair: a randomized, controlled trial. Bueno-Lledó J, FrancoBernal A, Garcia-VozMediano MT, et al. Ann Surg. 2021;273(6):1081-1086.

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Jolissaint JS, Dieffenbach BV, Tsai TC, et al. Surgical site occurrences, not body mass index, increase the long-term risk of ventral hernia recurrence. Surgery. 2020;167(4):765-771.

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Sahebally SM, McKevitt K, Stephens I, et al. Negative pressure wound therapy for closed laparotomy incisions in general and colorectal surgery: a systematic review and meta-analysis. JAMA Surg. 2018;153(11):e183467.

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Sartori A, Botteri E, Agresta F, et al. Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis. Hernia. 2021;25(2):501-521.

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Chopra K, Gowda AU, Morrow C, et al. The economic impact of closed-incision negative-pressure therapy in high-risk abdominal incisions: a cost-utility analysis. Plast Reconstr Surg. 2016;137(4):1284-1289.

The effect of negative pressure wound therapy on surgical site occurrences in closed incision abdominal wall reconstructions: a retrospective single surgeon and institution study. Seaman AP, Sarac BA, ElHawary H, et al. Hernia. 2021 May 19. doi:10.1007/ s10029-021-02427-3.

Systematic reviews combine information from randomized controlled trials with a wide variation in surgical technique, mesh type and clinical heterogeneity. The authors utilized trial sequential analysis to try to reduce false conclusions. Follow-up ranged from three to 60 months, which may influence capture of specific outcomes.

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Study is generalized and does not evaluate specific immunocompromised states and/or drug doses.

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Study is generalized and does not evaluate specific surgical methods or mesh types.

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Overall complication rate is higher than expected, but thought to be due to distribution in surgical method.

Negative pressure wound therapy (NPWT) is associated with a statistically significant reduction in surgical site occurrence (SSO) and surgical site infection rates.

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Study was powered for incisional hernia repair, but multiple repair methods and mesh types make applicability to a specific surgical practice difficult.

There is no statistically significant difference in hospital length of stay, seroma or hematoma formation and dehiscence with NPWT.

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Specifics of postoperative management were not included, and it is unclear why hospital length of stay is longer than what is expected in the literature.

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Only one type of NPWT system was used and may not be generalizable to other systems.

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Single-surgeon data may not be applicable to other surgeons.

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Perioperative care and surgical methods were not reported in the study.

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Retrospective review of prospectively collected data can be limited by misclassification and abstraction bias as well as loss to follow-up.

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NPWT was not associated with a statistically significant reduction in rates of SSO.

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NPWT was associated with a statistically significant reduction in rate of seroma formation.

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Decreased rates of SSO were associated with skin resection and being immunosuppressed.

IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2021

Benefits, Costs of Robotic Diaphragmatic Hernia Repair Weighed By ETHAN COVEY

recently published study has found that the costs associated with robotic diaphragmatic hernia repair may outweigh any potential clinical benefits compared with laparoscopic surgery. The findings add interesting context to ongoing discussions about the increased role of technology in surgical procedures (J Am Coll Surg 2021;233[1]:9-19.e2). “We set out to study robotic and laparoscopic approaches to diaphragmatic hernia repair [DHR] with the hypothesis that there would be a benefit within the first year postoperatively, related to the improved visualization and dexterity the robot provides,” said lead author Sujay Kulshrestha, MD, a surgeon at Loyola University Medical Center, in Maywood, Ill. The retrospective analysis included information from 2011 to 2018 on patients who underwent transabdominal DHR, and associated inpatient and outpatient encounters within 12 months after the operation. Data were gathered from the Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida. Of 8,858 identified patients who underwent DHR surgery, 67.3% were treated by laparoscopic DHR, 17.2% by open DHR, and 15.5% by roboticassisted DHR. The overall rate of robotic DHR increased from 5% in 2011 to 26.4% in 2018. Generally, patients who underwent open procedures were older, more likely to be male, had higher comorbidity scores, and were more likely to have Medicare or Medicaid insurance than those who underwent laparoscopic or robotic DHR. The researchers found that of the

three surgical approaches, open procedures were associated with the worst outcomes. Recipients of open DHR had a longer index hospital length of stay and were less likely to be discharged home than those undergoing laparoscopic or robotic DHR.

surgical approaches. “Our results did not identify a tangible clinical or financial benefit that outweighed robotic DHR’s up-front costs,” Dr. Kulshrestha said. “This points to the possible need to expand the follow-up period for research to better understand

‘Our results did not identify a tangible clinical or financial benefit that outweighed robotic DHR’s up-front costs. This points to the possible need to expand the follow-up period for research to better understand global effects of these operations—a lot of the complications we identified were beyond the first 90 days after the index operation.’ —Sujay Kulshrestha, MD However, when compared with laparoscopic surgery, robotic DHR did not fare well. The median length of stay for patients treated by robotic DHR was longer than for those undergoing laparoscopic DHR, and robotic DHR was associated with the highest overall index hospitalization costs. Upon matched analysis, there were no differences in the overall rate of postindex hospital-based encounters between

Journal Watch continued from the previous page

This study was a retrospective analysis of prospectively collected data from 2013 to 2020 in which the surgeon changed his practice from standard dressing of bacitracin ointment, petrolatum-based fine mesh gauze, gauze and tape to uniformly using NPWT after the cost-effectiveness analysis by Chopra et al (Plast Reconstr Surg 2016;137[4]:1284-1289). All ventral hernia repair patients with primary fascial closure and 30-day follow-up were included. A total of 258 patients were included for analysis: 159 (61.63%) undergoing NPWT and 99 (38.27%) having a standard dressing. Mean duration of NPWT was six days. There were higher rates of diabetes, skin resection and skin flaps in patients having NPWT. However, there was no difference in baseline characteristics in patients who did and did not develop SSOs.

global effects of these operations—a lot of the complications we identified were beyond the first 90 days after the index operation.” Shanu N. Kothari, MD, the vice chair of medical staff affairs at the USC School of Medicine in Greenville, S.C., also pointed to the need for longer-term data. “The follow-up was one year, so truly long-term follow-up data remains to be determined.”

There was a total of 65 (25.19%) SSOs; NPWT was not associated with a significant reduction in SSO (27.27% vs. 23.89%; P=0.544). Subanalysis by type of SSO showed NPWT was associated with decreased seroma rates (0.63% vs. 7.07%; P=0.004). Multivariate analysis showed decreased rates of SSO associated with skin resection (odds ratio [OR], 0.295; 95% CI, 0.0960.911; P=0.034) as well as when patients were taking immunosuppressive medications (OR, 0.411; 95% CI, 0.171-0.988; P=0.047), while NPWT had no association in decreased rates of SSO (OR, 0.843; 95% CI, 0.445-1.594; P=0.598). The authors demonstrate the importance of following one’s own data to determine applicability of published results to one’s own practice. Similar to the above study, the impetus for NPWT is to reduce SSOs and SSIs and, in turn, to reduce hernia recurrence. Although this study was published before the above randomized controlled trial (Ann Surg 2021;273[6]:1081-1086), the

Dr. Kulshrestha concurred. “In terms of future directions, similar studies with extended follow-up could help identify late postoperative complications, or provide an understanding of what operations are clinically beneficial and costeffective for prioritizing limited time at a robotic console.” Dr. Kothari also noted that the currently high costs of robotic DHR will likely decrease, potentially making the approach more affordable and leveling existing differences in pricing between institutions. “With a variety of robotic platforms in various iterations of development, I would presume that the charges related to robotic platforms will continue to go down with time,” he said. Most concerning, according to Dr. Kothari, was the higher rate—17.2%— of patients who still underwent open DHR, and the fact that frequently they were the sickest individuals. “These are exactly the risk factors of patients who would benefit the most from a minimally invasive approach, whether it be laparoscopic or robotic,” he said. “The tendency, even in an urgent setting, to do open surgery ‘because it is faster and better for the patient’ is unfounded by studies including this one. These patients spend an extended time in the hospital, are more likely to go to an extended care facility, and in this analysis, the charges were equivalent to the use of a robotic platform.” Dr. Kothari added that the true impact of these various approaches over time is unknown, especially as reoperation rates in the study were very low. “The real question that remains unanswered is the following: What is the financial burden of symptomatic diaphragmatic hernias on health care expenditures and, what, if anything, can we as surgeons do to mini■ mize recurrence rates?” he said.

authors are able to utilize their own data to determine the benefit, if any, of NPWT for their ventral hernia repair patients. Variables that may affect outcomes— such as surgical method, mesh type, hernia width, perioperative care, NPWT system type and presence of drains—can make drawing conclusions unclear. But, with a single surgeon, it can be hypothesized that surgical and perioperative care are somewhat standardized, and the variability within the data set is fairly minimal. Limitations of the study include those inherent in a retrospective review of prospectively collected data, such as misclassification and abstraction bias, and a single surgeon’s practice may not be generalizable to all surgical practices. An interesting finding from this study was that, yet again, immunosuppression does not appear to be associated with increased rates of SSO for hernia repair. Based on the methods of this surgeon’s practice, NPWT is not associated with statistically significant lower rates of SSO. ■

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AUGUST 2021 / GENERAL SURGERY NEWS

Surgery Leads to Fewer Readmissions Than Nonoperative Approach for Inguinal Hernia By BOB KRONEMYER

lthough readmission after nonelective hospitalization for inguinal hernia is rare, surgical intervention reduced the likelihood of readmission compared with nonoperative management, according to a retrospective review of 2010-2014 data from the Nationwide Readmissions Database. The study, published in Hernia (2021 Jul 3. doi:10.1007/s10029-021-024415) also found that surgical intervention increased hospital length of stay (LOS) and cost of care over nonoperative management. “We were curious to see how helpful the NRD would be in addressing a clinically relevant question,” said principal investigator Hanna Jensen, MD, PhD, an assistant professor of surgery at the University of Arkansas for Medical Sciences (UAMS), in Little Rock. “We chose to investigate hernia surgery because it is one of the most common surgical procedures performed in the United States.” Of the 14,249 patients ages 18 years and older who were admitted nonelectively for a primary diagnosis of inguinal hernia and met inclusion criteria, 63.1% were operative cases and 36.9% were nonoperative cases. The readmission rate within 90 days of the initial admission was 0.49% for surgical patients and 1.78% for nonsurgical patients (P<0.01). However, the mean LOS was longer for surgical than nonsurgical patients: 3.27 vs. 2.76 days (P<0.01). The mean total cost for readmission was also higher for surgical patients: $9,597 vs. $7,167 (P<0.01). The nonsurgical population was on average older and had more chronic conditions. Of the patients initially managed nonsurgically, 62.6% were treated surgically within 90 days of the initial admission. “The study results were as expected,” said Dr. Jensen, the director of clinical research for trauma and acute care surgery at UAMS. “If the treating facility opted to not operate on the initial admission, the readmission rate was clearly higher, while still very reasonable.” A surgical admission often lasts slightly longer than a nonsurgical one, “so we were not overtly surprised about this outcome,” Dr. Jensen said. “Repairing symptomatic inguinal hernias electively is always the optimal approach and likely is associated with the shortest LOS. A nonelective admission for inguinal hernia implies some complications, which likely extends LOS.”

Because the rate of readmission after nonelective surgery for inguinal hernia was extremely low, Dr. Jensen and her colleagues do not believe there are any major issues that need to be addressed, based on the large national study. “However, our data set does not allow us to examine causality or draw robust conclusions about what factors may have predisposed patients to being readmitted,” she said.

In addition, the higher rate of readmission among nonsurgically treated patients “begs the question of whether an operation might have been indicated already on their initial admission,” Dr. Jensen said. “The NRD does not allow us to explore the reasons why any individual patient underwent surgery or received medical treatment only. Thus, we hope that those pathways are closely

evaluated in institutional or multi-institutional studies in the future. Certainly, the reason to refrain from surgical treatment needs to be clear and well justified.” Co-author Avi Bhavaraju, MD, also an assistant professor of surgery at UAMS, said the biggest downside in managing inguinal hernia patients nonsurgically “is the risk of having to be readmitted continued on page 24

The mission of the Americas Hernia Society is to advance the science and treatment of hernia. The vision of the Americas Hernia Society is to be the worldwide authority on hernia surgery. AHS fulfills its mission and vision by, among other things: • Hosting periodic meetings for open presentation and discussion of scientific material concerning subjects of common interest. • Cooperating in educational endeavors with groups of similar interest throughout the world. • Initiating and cooperating in the publication of a journal and/or newsletter on the subject or hernia/abdominal wall abnormalities. • Undertaking projects of scientific interest to seek information and otherwise serve the mission of the organization. Americas Hernia Society www.americasherniasociety.com (847) 228-3302 | info@americasherniasociety.org

The Americas Hernia society offers a number of benefits to our members. We encourage any surgeon interested in abdominal wall abnormalities to join.

MEMBERSHIP BENEFITS • Discounted meeting registration at AHS/EHSmeetings • Educational Webinars • Online member search for patient referral • Journal Hernia • AHSQC

OPINION

GENERAL SURGERY NEWS / AUGUST 2021

AHS Presidential Address: It’s Just a Hernia, Until It’s Not continued from page 11

is often uncontrolled in the best scientific studies. Expertise, judgment and proficiency improve outcomes. In inguinal hernia repair, our goal as surgeons is to lower our personal risk for complication to less than 0.5%, but that number can and will never be zero. Whatever can happen in surgery, will happen. Let me give you an example. A 70-ishyear-old, robust gentleman underwent an uncomplicated outpatient laparoscopic total extraperitoneal repair. Five days later, he was admitted with an ileus, nothing else on examination, labs and CT scan. On postoperative day 7, on rounds, feculent output came out the periumbilical port. Laparoscopy identified fecal leakage in the preperitoneal space with a clean intraabdominal cavity. This was washed out; a laparoscopic right colectomy was performed; and mesh was removed. A Shouldice repair was performed to address the open inguinal canal and hernia. After a prolonged hospital course, sepsis, abscess drainages, rehabilitation, three months later, the patient went home—a fairly horrible course for a “simple” inguinal hernia repair. In retrospect, the patient reported that his open appendectomy as a young man was accompanied by a long hospitalization with him almost dying from peritonitis. Review of the operative video demonstrated no break in technique or obvious colon injury. A shear injury during dissection of the lateral peritoneal flap likely led to this delayed colon injury with the colon fused to the prior incision. The data and guidelines clearly support a minimally invasive approach; but if only the patient had an open Lichtenstein repair, he would have not been a victim of anatomy and probability. Even more ironic is that he is my patient at the Lichtenstein Amid Hernia Clinic, where we clearly can perform a pretty good open Lichtenstein. And he is a physican. And a professor. And a colleague. And my friend. While I am still below my aspirational 0.5% complication rate for inguinal hernia repairs, and thankfully I could operatively clean up my own mess, I could have done better. This job is always humbling. All for a “simple” inguinal hernia. As surgeons, we strive for perfection but cannot be perfect, and good hernia surgery demands that we be good general surgeons. In an ever-specializing field, Hernia is, and always will be, central to general surgery and the bread and butter of most general surgeons’ practices. Herniorrhaphy is one of the first operations that we teach our interns, the first cases that we book as an independent young attending, and by volume, the most common

operation that we as general surgeons perform for patients. “It’s just a hernia,” until it’s not. Simple procedures can quickly become complex, and our complicated cases in Hernia become more challenging as we work to provide patients with durable repairs, functionality and better outcomes. The field of Hernia has transformed and expanded to encompass a broader complexity of disease and variety of techniques. With novel techniques,

advances in prosthetics, robotic assistance, advanced reconstructive operations, enhanced recovery pathways and continuous quality improvement initiatives, there is more for surgeons to learn than ever. Abdominal wall reconstruction; component separation techniques; minimally invasive and robotic surgery; diaphragmatic, perineal, lumbar, flank, parastomal hernias; athletic pubalgia; chronic groin and abdominal pain; and management of enteric, infectious and

inflammatory complications of hernia clearly demonstrate that the state of the art is anything but simple. We have made significant strides reducing recurrence rates, decreasing morbidity and mortality, shortening hospital stays, dropping infection rates, and generally improving outcomes. With such rapid progress and change, never has it been more important to optimize patient outcomes though education, standardization of techniques,

For complex hernia repair

INDICATIONS STRATTICE™ Reconstructive Tissue Matrix (RTM), STRATTICE™ RTM Perforated, STRATTICE™ RTM Extra Thick, and STRATTICE™ RTM Laparoscopic are intended for use as soft tissue patches to reinforce soft tissue where weakness exists and for the surgical repair of damaged or ruptured soft tissue membranes. Indications for use of these products include the repair of hernias and/or body wall defects which require the use of reinforcing or bridging material to obtain the desired surgical outcome. STRATTICE™ RTM Laparoscopic is indicated for such uses in open or laparoscopic procedures. These products are supplied sterile and are intended for single patient one-time use only. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS These products should not be used in patients with a known sensitivity to porcine material and/or Polysorbate 20. WARNINGS Do not resterilize. Discard all open and unused portions of these devices. Do not use if the package is opened or damaged. Do not use if seal is broken or compromised. After use, handle and dispose of all unused product and packaging in accordance with accepted medical practice and applicable local, state, and federal laws and regulations. Do not reuse once the surgical mesh has been removed from the packaging and/or is in contact with a patient. This increases risk of patient-topatient contamination and subsequent infection. For STRATTICE™ RTM Extra Thick, do not use if the temperature monitoring device does not display “OK.” PRECAUTIONS Discard these products if mishandling has caused possible damage or contamination, or the products are past their expiration date. Ensure these products are placed in a sterile basin and covered with room temperature sterile saline or room temperature sterile lactated Ringer’s solution for a minimum of 2 minutes prior to implantation in the body. Place these products in maximum possible contact with healthy, well-vascularized tissue to promote cell ingrowth and tissue remodeling. These products should be hydrated and moist when the package is opened. If the surgical mesh is dry, do not use.

EXTENDED HERNIA COVERAGE 2021 23

AUGUST 2021 / GENERAL SURGERY NEWS

and research to provide evidence that progress translates to better outcomes and value. The Americas Hernia Society (AHS) is leading this change, carrying out our missions of education, advocacy, research, outreach and stewardship. The AHS WISE (Web Information Social Media and Education) initiative, led by Drs. Vedra Augenstein, Conrad Ballecer, Megan Nelson and Sal Docimo, and our robust Education Committee assembles incredible state-of-the-art lectures accompanied by biweekly moderated sessions on the International Hernia Collaborative Facebook page for our

As surgeons, we strive for perfection but cannot be perfect, and good hernia surgery demands that we be good general surgeons. members and the Hernia community to interact. After a pandemic hiatus, our Hernia Compact Program for residents and fellows, Open to Robotics Labs, and Advanced Surgical Skills Handson Labs have resumed to help surgeons to adopt new techniques and skills in a mentored fashion. The AHS has been tirelessly working to advocate for better, more accurate procedure-specific coding and compensation

for Hernia. Led by AHS governors Drs. Scott Roth and John Fischer, we are well into the years-long process to join the RVS Update Committee, advocating to fairly and appropriately value the complexity, diversity and breadth of the services that hernia surgeons provide. The AHS continues to promote the cutting-edge research essential to move our field forward. In collaboration with our partners at the Abdominal

WITH THE STRATTICE™ RTM is designed to be positively recognized, allowing for regeneration and a repair that holds.1,2,* *Correlation of these results, based on animal studies, to results in humans has not been established.

In a recent retrospective evaluation of biologic meshes, including STRATTICE™,

91.7 7 YEARS %

†

OF PATIENTS WERE RECURRENCE-FREE AT POST-OP3,†

Includes porcine and bovine acellular dermal matrices (ADMs) (n = 157). Bridged repair and human ADM were excluded from the study group.

For more information, contact your Allergan Aesthetics representative or visit hcp.StratticeTissueMatrix.com PRECAUTIONS (continued) Certain considerations should be used when performing surgical procedures using a surgical mesh product. Consider the risk/benefit balance of use in patients with significant co-morbidities; including but not limited to, obesity, smoking, diabetes, immunosuppression, malnourishment, poor tissue oxygenation (such as COPD), and pre- or post-operative radiation. Bioburden-reducing techniques should be utilized in significantly contaminated or infected cases to minimize contamination levels at the surgical site, including, but not limited to, appropriate drainage, debridement, negative pressure therapy, and/or antimicrobial therapy prior and in addition to implantation of the surgical mesh. In large abdominal wall defect cases where midline fascial closure cannot be obtained, with or without separation of components techniques, utilization of the surgical mesh in a bridged fashion is associated with a higher risk of hernia recurrence than when used to reinforce fascial closure. For STRATTICE™ RTM Perforated, if a tissue punch-out piece is visible, remove using aseptic technique before implantation. For STRATTICE™ RTM Laparoscopic, refrain from using excessive force if inserting the mesh through the trocar. STRATTICE™ RTM, STRATTICE™ RTM Perforated, STRATTICE™ RTM Extra Thick, and STRATTICE™ RTM Laparoscopic are available by prescription only. For more information, please see the Instructions for Use (IFU) for all STRATTICE™ RTM products available at www.allergan.com/StratticeIFU or call 1.800.678.1605. To report an adverse reaction, please call Allergan at 1.800.367.5737. For more information, please call Allergan Customer Service at 1.800.367.5737, or visit hcp.StratticeTissueMatrix.com. References: 1. Connor J, McQuillan D, Sandor M, et al. Retention of structural and biochemical integrity in a biological mesh supports tissue remodeling in a primate abdominal wall model. Regen Med. 2009;4(2):185-195. 2. Sun WQ, Xu H, Sandor M, Lombardi J. Process-induced extracellular matrix alterations affect the mechanisms of soft tissue repair and integration. J Tissue Eng. 2013;4:2041731413505305. doi: 10.1177/2041731413505305. 3. Garvey PB, Giordano SA, Baumann DP, Liu J, Butler CE. Long-term outcomes after abdominal wall reconstruction with acellular dermal matrix. J Am Coll Surg. 2017;224(3):341-350. STRATTICE™ and its design are trademarks of LifeCell Corporation Corporation, an AbbVie company company. © 2021 AbbVie. All rights reserved. STM147027 05/21

DON’T MESH AROUND

Core Health Quality Collaborative, the AHS annually awards five Hernia and Abdominal Wall research scholarships at the annual meeting, along with the AHS Women Issues in Hernia Surgery Research Scholarship founded by Dr. Shirin Towfigh. We actively are working to recruit new, diverse, talented voices to participate in and lead the AHS. As the umbrella Hernia Society for the Americas, we enjoy and promote robust engagement with our Latin American and Canadian colleagues and our world Hernia partners. We continue to work for greater opportunity and equality in our field, society and communities for all our members, surgeons and patients alike. We are proud of the steps that have been accomplished at the AHS to keep our society open and inclusive, while understanding there is much more work ahead to live up to our hopes and expectations. The AHS Foundation continues to promote charitable and humanitarian outreach with a stronger, formal relationship with Hernia Repair for the Underserved, the charity started by AHS founders Drs. Chuck Filipi, Arthur Gilbert and Bob Fitzgibbons, and includes many of our AHS past presidents and leadership. Now more than ever, we are reminded of the importance of helping one another and advancing our field by taking care of the underserved and serving our neighbors here and abroad. Without hyperbole, the last year has been perhaps the most disruptive, challenging and transformative in most of our personal lives and professional careers. Despite this adversity, we find the field of Hernia at an exciting time. The next chapter in Hernia and Abdominal Wall Surgery will be exciting. We at the AHS will lead this change and help define our growing field. Hernia is inherently a collaborative, collegial, friendly discipline in which surgeons are happy to share, mentor and raise the bar for all so that we can all do better for our patients. We can never be perfect, but we can work together to continue to try. I invite each of you to join the AHS, actively participate in your society and help us lead this exciting change. After a long COVID-19 winter, on behalf of the AHS, Dr. Jeff Janis our program chair, and the Program Committee, we are excited to invite all of you to meet next month in Austin, Texas, in person, ■ for the 2021 AHS annual meeting. —Dr. Chen is a professor of clinical surgery at the David Geffen School Medicine at UCLA, the director of the Lichtenstein Amid Hernia Clinic, both in Los Angeles, and the president of the Americas Hernia Society.

IN THE NEWS

Hernia Mesh Talk continued from page 11

After a thorough exam, Shirin Towfigh, MD, the director of the Beverly Hills Hernia Center, in California, suspected Eller was having a rare but serious reaction to the polypropylene mesh. “This was the first time a doctor had even mentioned the possibility of a severe complication or systemic reaction from the mesh,” Eller recalled. Eller’s experience highlights a few major issues now taking center stage in the hernia surgery space: mounting concerns about the safety of mesh, lingering unknowns about the long-term complications associated with hernia repair, and a growing push to improve surgeon– patient communication about these risks and unknowns. The vast majority of patients do fine with hernia mesh, but about 5% of patients may have a major complication, according to a recent analysis (JAMA 2016;316[15]:1575-1582). At the same time, patients with non-mesh repairs are much more likely to experience a recurrence (18.3% vs. 12%), another factor associated with increased pain. “What many patients don’t realize is only a small fraction of people have a bona fide allergy or serious inflammatory reaction to the mesh,” Dr. Towfigh said. In other words, while mesh may be the downstream cause of a complication when, for instance, the material migrates, surgeons still need more data to tease out the extent to which other factors—surgeon technique, reinforcement approach, mesh placement and scar tissue—contribute to or cause the problem. Despite this complexity, hernia mesh has become the poster child for postoperative issues. In a 2020 study analyzing growing chatter about hernia mesh on Twitter and Facebook between December 2016 and August 2019, Dr. Towfigh and her colleagues found 95% of tens of thousands of Facebook comments discussed hernia mesh in a negative light, and more than one-third of 1.1 million tweets about hernia mesh were negative (Am Surg 2020;86[10]:1351-1357). Several top commenters had affiliations with

GENERAL SURGERY NEWS / AUGUST 2021

law firms that, over the past five years, have invested tens of millions of dollars advertising hernia mesh complications and pushing class action lawsuits. “If you have a hernia mesh, a TV and pain, it’s easy to blame the mesh,” said Michael J. Rosen, MD, the director of the Cleveland Clinic Center for Abdominal Core Health. “Concerns about mesh have dramatically changed the conversation between hernia surgeons and patients. I now get questions about mesh from every patient I operate

on, and it’s important to be honest with patients that, although serious mesh complications are rare, there are still a lot of unanswered questions about longterm outcomes.”

Challenges Identifying a Mesh Complication In 2017, Eller underwent allergy testing to determine whether she, in fact, was reacting to her mesh. The test involved placing a few small pieces of mesh on her back and waiting to see whether she’d respond. “I had a severe reaction to the

Readmissions continued from page 21

to the hospital for the same problem and the moderate chance of requiring surgical intervention if readmitted. The inconvenience and quality-of-life issues associated with readmission to the hospital should also be taken into account.” Dr. Bhavaraju noted the results of the study should be looked at in context, partly due to the design’s retrospective and database nature. “While the percentage of readmitted patients who were initially managed nonoperatively is low, readmission is still more than

polypropylene material and a more minor reaction to a hybrid mesh with some polypropylene,” she said. Although the results helped confirm Dr. Towfigh’s hunch, allergy testing often provides limited to no clarity. In another recent analysis, Dr. Towfigh reported mesh allergy testing had a falsenegative rate of 40% or more. “In most instances, we have noo definitive way to determine if mesh is to blame for a patient’s pain,” she said. If there’s no

visible allergic reaction to the material, “often the best evidence is whether a patient’s symptoms resolve after mesh removal. But removing mesh is also not a cureall. In 2018, Dr. Towfigh shared her center’s experience removing 105 mesh from 97 patients over 4.5 years (Hernia 2018;22:953-959). According to the analysis, the major reasons for mesh removal included infection, meshoma and pain. The authors also cautioned that mesh extraction can be technically complex and comes with its own issues, including

three and a half times more likely if the hernia was initially managed without surgery compared to those who were initially fixed,” he said. “We can therefore reasonably conclude that patients with symptomatic inguinal hernias would probably benefit from having their hernias repaired during the index admission because those managed nonoperatively have a higher chance of short-interval readmission for the same problem and will ultimately require operative fixation of the hernia.” Although the total cost of care was higher in the operative group, “they have a lower chance for readmission and the associated risks, complications and lifestyle

a neurectomy and a high risk for recurrence. What’s worse, a patient’s pain may not improve after removing the mesh. “It can feel like we’re chasing our tails when operating for pain,” said Alfredo Carbonell, DO, FACS, FACOS, the codirector of the Hernia Center of Prisma Health and the University of South Carolina School of Medicine, in C Columbia. But predicting which patients might have a lifealtering reaction to mesh before surgery is also nearly impossible. Ineffective post-market survveillance along with poor patient follow-up are, in large part, to blame for this knowledge gap. “If you’re going to implant something that is expected to last a lifetime, surgeons, industry, hospitals, insurers and the FDA need to be following those patients and implants on a long-term basis to make sure everything is safe,” said Benjamin Poulose, MD, MPH, a general surgeon at The Ohio State University (OSU) Wexner Medical Center, in Columbus, and the co-director of OSU’s Center for Abdominal Core Health. “Given challenges with patient follow-up and postmarket surveillance, we still have limited data to guide decisions about the best individualized option for patients.”

Creating a Patient–Surgeon Team After an umbilical hernia repair in August 2014, Eric Beauford began feeling an intense burning sensation across his midsection. “My abdomen was so tender, even a shirt touching my skin hurt,” Beauford said. Beauford, at the time an active man in his early 40s, returned to his general surgeon to explain his symptoms, and got the brush-off. The surgeon told him his pain should resolve in several weeks and to continue wearing an abdominal wrap. The pain only got worse. After some research, Beauford began to wonder whether his symptoms could be related to the implanted porcine biologic mesh—a possibility not discussed before surgery.

adjustments that come along with a second hospital stay,” Dr. Bhavaraju said. Dr. Bhavaraju said it would be interesting to investigate which patient factors in the nonoperatively managed group might predict failure of this approach and eventual readmission and crossover to surgical management. “If we can elucidate these predictive factors, then perhaps we can more effectively triage those higher-risk patients into an initial operative management strategy at the index admission.” Dr. Jensen added,: “Obviously, the universal goal is to ensure that all patients receive prompt and appropriate care with minimal risk of readmissions down the road.” ■

EXTENDED HERNIA COVERAGE 2021 25

AUGUST 2021 / GENERAL SURGERY NEWS

But his surgeon dismissed the question. And when Beauford’s insurance coverage for surgical follow-up had ended, “my surgeon put his hand on my shoulder and walked me out the door,” he recalled. Some patients, like Beauford, feel their concerns are disregarded when a complication arises. But many hernia experts are listening. The Abdominal Core Health Quality Collaborative (ACHQC) has spearheaded efforts to bring industry leaders and patients together and collect long-term data on patient outcomes. Eller and Beauford were asked to join the ACHQC Patient Advocacy Committee. “A unique part of the QC’s agenda is to help enhance the doctor–patient relationship and make patients informed partners in their care,” said Paul Szotek, MD, FACS, the director and CEO of Indiana Hernia Center, in Indianapolis. To foster that partnership, experts first need to understand patients’ expectations before surgery and experiences after surgery. At a June ACHQC webinar titled “Enhancing Outcomes: The Patient Perspective,” Bryan Ellis, DO, presented his research on patient- and surgeon-reported recurrences after ventral and inguinal hernia repairs, and found that their perceptions did not necessarily align. Of 36,157 mostly mesh-reinforced ventral hernia repairs, 20% of patients reported a bulge or recurrence at one year compared with 11.5% of surgeons. With inguinal hernia repairs, patient and surgeon perceptions aligned more closely: Almost 7% of patients reported a recurrence compared with 9% of surgeons. But a 2016 study reported a much wider gap. The analysis found that patient-perceived adverse events were about five times higher than those recorded in the Swedish Hernia Register (Int J Surg 2016;35:100-103). “What I consider a successful repair may not be what a patient considers successful,” Dr. Carbonell said. “That’s why I always ask my patients what they want to get from a hernia repair and give them a realistic sense of what they might expect. The reality is, as physicians, we are part of a team with the patient and need to be sensitive to their concerns and let them know we’re with them for the long haul if they do have a complication.” Experts also stressed the importance of providing extensive education before surgery. That includes spending time with patients to listen and address their questions about hernia mesh, being honest with them about the knowns and unknowns, and embracing a shared decision-making approach to their care. Dr. Szotek, for instance, walks patients through different techniques, mesh or no-mesh options, and the benefits and

risks of each. He also uses a texting app that includes educational videos and offers a direct line of communication with him, in case patients have questions throughout the process. “Communication before and after surgery is everything,” Dr. Szotek said. “The idea is to give patients a choice and make the doctor–patient relationship front and center.” Given a growing patient demand for non-mesh options, Dr. Poulose reintroduced Shouldice repairs into his practice for patients with inguinal hernias. “Even with a higher chance of recurrence, some

patients are willing to make that trade-off and avoid mesh,” he said. “And it’s important to give patients who are eligible for a non-mesh repair a choice.” Beauford and Eller hope their stories will give hernia surgeons a window into the patient experience and help future patients navigate their care. “I’m not giving up, and I hope my situation can help improve communication so that patients’ concerns and symptoms are heard and acknowledged,” Eller said. Drs. Rosen and Poulose see this moment as an opportunity to change the culture of the disease.

“Hernias are much more complicated than we thought,” said Dr. Rosen, the medical director of the ACHQC. “Surgeons need to take mesh and other postoperative complaints seriously, and we need long-term outcomes to make the best decisions for our patients.” Ultimately, Dr. Poulose said, “the current medical-legal climate is bringing up a necessary conversation in a convoluted way, but if these discussions help us make mesh, technique, postmarket surveillance and patient selection more optimal, something positive ■ can result.”

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The Scientific Greats: A Series of Drawings By MOISES MENENDEZ, MD, FACS

Marie Skłodowska Curie (1867-1934) Marie Curie was a Polish and naturalized-French physicist and chemist who conducted pioneering research on radioactivity. She was the first woman to win a Nobel Prize, the first person and only woman to win twice, the only person to win a Nobel Prize in two different sciences, and was part of the Curie family legacy of five Nobel Prizes. Curie was born Marya Skłodowska in 1867 in Warsaw. Her family struggled under a repressive Tsarist regime, which was trying to stamp out vestiges of Polish culture. As a teenager, Curie made a pact with her sister Bronya: She would support Bronya while she was in medical school in Paris, and then Bronya would pay Curie’s way. From the age of 17, for six years, Curie worked as a governess and tutor, while attempting to study in her spare time. At the age of 24, she enrolled at the Sorbonne University. She could not attend the University of Warsaw, as her brother had; the Russian government prohibited women from attending university anywhere in its empire. It was in Paris, in 1894, where she met Pierre Curie, a scientist working in the city, and who she married a year later. For the following years, Curie and her husband handled radioactive materials without the proper protection since they were not fully aware of the dangers of radiation. Curie’s discovery of radium and polonium initiated a new area of chemistry, radium chemistry, and, in turn, paved the way for the application of radioisotopes in medicine, industry and many other areas. Pierre was killed in an accident. Despite being a single mother of two and a widow, Curie continued her research and teaching, as she took over Pierre’s teaching position at Sorbonne.

Ridesharing continued from page 1

and disability in people under the age of 65,” said lead study author Christopher Conner, MD, PhD, a neurosurgery resident at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth). “The reality of the situation is that once the accident or the trauma has occurred, we’re playing catch up.

Motor vehicle crash trauma decreased by 23.8% during peak trauma periods (Friday and Saturday evenings) after the introduction of Uber ridesharing services in Houston.

In 1911, Curie won her second Nobel Peace prize in chemistry. Radiotherapy was developed from the discoveries of Curie, who was convinced that ionizing radiation could be the perfect weapon in the fight against cancer. Since then, radiotherapy has seen continual improvements through technological progress. During World War I, Curie was involved in the first use of radiology to treat wounded soldiers, and she trained the army’s radiologist nurses at what is now known as the Curie Institute, in Paris. At the time, medicine had few means of diagnosis and the use of x-rays was just beginning. With the outbreak of the conflict, Curie volunteered to operate the radiology equipment near the front line. However, these were few and not mobile. The engineers had adapted a Renault truck and placed an x-ray machine on it, thus creating the first mobile radiology unit that served to support medical aid on the battlefront. In a short time, the number of these vehicles increased, and Curie, then 47, trained about 50 nurses in the use of these radiology devices, including her daughter Irene. Curie died in 1934, aged 66, in France, due to aplastic anemia brought on by exposure to radiation while carrying test tubes of radium in her pockets during research and in the course of her service in the World War I mobile x-ray units that she had set up. In Paris, April 20, 1995, making amends for centuries of Gallic sexism, male leaders watched as Francois Mitterrand, the former president of France, gave the eulogy speech while transferring the ashes of Curie and her husband Pierre to the famous Pantheon. This episode made Curie the first woman to be buried in the Pantheon for her own accomplishments. Ironically, there is an inscription at the façade of this monument that reads: “Aux grands hommes la patrie reconnaissante.” (The grateful nation recognizes great men.) Despite her greatness, Curie suffered from the male chauvinism prevalent during her heyday, and she was

So, by far, the best treatment that we have is prevention.” Dr. Conner explained that this study was motivated by the observation among his colleagues that there had been a decrease in car accidents on Friday and Saturday nights. The researchers hypothesized that ridesharing services had a significant effect on the number of motor vehicle crash traumas that occurred on these weekend evenings, when many people may be using the services to avoid impaired driving. To investigate this potential relationship, Dr. Conner and his colleagues obtained data from Uber, Google and hospital records from the two major trauma centers in Houston. “Once we were able to dig into that with hospital-level data, which is data that’s accurate down to the hour, we were able to tease apart these details,” Dr. Conner said. “I think people had been unable to do so with the data in the past.”

Marie Skłodowska Curie (1867-1934) 2014 Work was done on white watercolor paper and graphite, 20×24 Artist: Moises Menendez, MD, FACS

denied membership in the Academy of Sciences, an all■ male institution at the time.

Sources Carvalho FP. As descobertas científicas de Marie Curie e o seu legado à ciência e à humanidade. Instituto Tecnológico e Nuclear. 2011;3(2):1-11. Goldsmith B. Obsessive Genius: The Inner World of Marie Curie (Great Discoveries). Atlas Books; 2005:13-17. Grammaticos PC. Pioneers of nuclear medicine, Madame Curie. Hell J Nucl Med. 2004;7(1):30-31.

The researchers found that motor vehicle crash trauma decreased by 23.8% during peak trauma periods (Friday and Saturday evenings) after the introduction of Uber ridesharing services in Houston. Analysis of patient demographics showed that the reduction in motor vehicle crash trauma was most pronounced among people younger than 30 years (rate of reduction, 38.9%). “Empirically, the majority of motor vehicle crashes that result in injuries requiring people to come to our trauma center are in some way due to impaired driving—either the injured patient or someone else who hit the injured patient,” said study author John Harvin, MD, an associate professor of surgery at McGovern Medical School at UTHealth. “It only makes sense that decreasing the amount of impaired driving would result in fewer injuries.” In addition, rideshare use was linked to a reduction in convictions for impaired driving (incidence rate ratio, 0.76; 95% CI, 0.73-0.78; P<0.001). Notably, convictions fell the most in Houston’s core.

“As someone who has lived here for 17 years, that made perfect sense,” Dr. Conner said. “I thought, that’s exactly where the bars are; that’s where all the people under 30 are.” An important caveat to the study is that the data are only representative of the Houston area, which is a heavily cardependent city. “It would be interesting to look at other cities with different layouts and public transport to see what effect, if any, ridesharing may have had,” Dr. Harvin said. In the future, the authors plan to look at national trends by obtaining similar high-granularity data from across the country. Ultimately, Dr. Conner hopes these data will help people to “always think twice before driving impaired. “I hope, when we talk about rideshares and their impact on our society, we at least acknowledge the fact that this is something that is of major benefit, he said. “I think that it’s definitely something that we need to consider as part of the broader conversation.” ■

IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2021

Colorectal Liver Metastases continued from page 1

missing live metastases, which are not visible on high-quality liver imaging and not detectable in the OR (Curr Colorectal Cancer Rep 2014;10:204-210). Dr. Aloia argued that disappearing liver metastases should absolutely be resected. “It is rare for patients who present with resectable liver metastases treated with a short course of neoadjuvant chemotherapy to develop a disappeared liver metastasis, and in the rare case that they do develop a disappeared liver metastasis, the tumors are rarely missing liver metastases but can typically be detected intraoperatively,” Dr. Aloia said. According to Dr. Aloia, disappearance on imaging rarely equates to a pathologic complete response (J Gastrointest Surg 2010;14[11]:1691-1700; Cancer 2010;116[6]:1502-1509). “We cannot rely on the imaging to tell us that a lesion that is about to disappear will become a nonrecurrent tumor,” he said. Dr. Aloia said at-risk lesions, most commonly encountered as small tumors in a multifocal patient, should have fiducial markers placed prior to preoperative systemic chemotherapy. Short-course preoperative systemic therapy should be halted as soon as a response is identified in a resectable patient (Lancet 2008;371[9617]:963-965). “If the intent is to treat with preoperative therapy limited to only two or three months, this strategy combined with judicious fiducial marker placement are both well used preventative measures to avoid the distress of missing metastases in the operating room,” he said. Dr. Aloia said becoming an expert in intraoperative ultrasound is important (J Am Coll Surg 2005;201[4]:517-528).

“Certainly in the setting of a previously treated patient, direct ultrasound examination with the probe on the liver may be our best imaging modality, and we need to maximize its ability to identify small and disappeared lesions to make sure that they do not reach the category of a missing lesion in the operating room,” he said. Dr. Aloia pointed out that surgeons have many surgical tools to choose from these days. For patients with bilobar colorectal liver metastases, surgical options now include anatomic hepatectomy, one-stage parenchymal sparing hepatectomy, traditional two-stage hepatectomy with or without portal vein embolization, associated liver partition and portal vein ligation for staged hepatectomy, local ablative techniques, and hepatic arterial infusion therapy (Surgery 2017;162[1]:12-17). “As we look at the spectrum of lesion status from progressing to all the way to missing lesions, it is really the responding and disappearing, but not disappeared or missing lesion, that has the best prognosis with surgery,” Dr. Aloia said. “Therefore, I would argue that the disappearing liver metastases is the ideal clinical situation that should be operated on.”

Observing Disappearing Liver Metastases Is a Good Option Dr. Leah Melstrom, a liver surgeon at City of Hope, offered a somewhat contrary opinion. “I am here to argue the point today that, indeed, resection of disappearing colorectal liver metastases is not a mandate. Not all disappearing colorectal liver metastases merit resection,” Dr. Melstrom

‘As we look at the spectrum of lesion status tus from progressing to all the way to missing lesions, ions, it is really the responding and disappearing, g, but not disappeared or missing lesion, that has the best prognosis with surgery. Therefore, I would argue that the disappearing liver metastases ases is the ideal clinical situation that should be operated on.’ —Thomas Aloia, MD said. “There is a reasonable chance that a disappearing lesion will not return, and I will argue that if it does return, there will remain treatment options. And lastly, and most importantly, if it does return, this small lesion will not likely dictate the survival of your patient.” Dr. Melstrom pointed out that isolated liver metastases can account for up to 25% of metastatic colorectal cancer presentation. “Since the early 2000s, the response rates have been upwards of 70% with FOLFOX [5-fluorouracil, leucovorin, oxaliplatin], FOLFIRI [irinotecan, 5-fluorouracil, leucovorin] and the biologics, which include bevacizumab, panitumumab [Vectibix, Amgen] and cetuximab [Erbitux, ImClone],” she said. “This improvement in systemic therapy has led to the phenomenon of disappearing liver colorectal metastases to occur in up to 5% to 25% of patients based on the series that you look at.” Dr. Melstrom said all can agree that resection of isolated colorectal liver metastases is associated with improved survival, and pathologically complete response to chemotherapy in these lesions is also associated with improved survival. However, disappearing colorectal liver metastases on cross-sectional imaging after

T Table 1. Sensitivity and Specificity at Diagnosis of Colorectal Liver Metastases C Sensitivity

Specificity

74%

93.9%

CT C

82.1%

73.5%

MRI M

93.1%

87.3%

PET/CT P

Source: J Magn Reson Imaging. 2018;47(5):1237-1250. S

chemotherapy does not routinely equate to a pathologic or clinical complete response (Dig Surg 2011;28[2]:114-120; Cancer 2010;116[6]:1502-1509; J Gastrointest Surg 2010;14[11]:1691-1700). In a systematic review of 15 studies involving 479 patients with disappearing colorectal liver metastases, the median age was 59 years, the median number of lesions per patient was one to 8.8, the median size of liver metastases prior to chemotherapy was 1.07 cm, and the median number of cycles of chemotherapy was approximately eight (Surg Oncol 2019;29:7-13). Factors found to be associated with disappearing colorectal liver metastases included lesions that were smaller than 2 cm, increased number of colorectal liver metastases (at least three), presentation of synchronous disease, history of oxaliplatin-based chemotherapy and increased number of treatment cycles. “Just as size and number of these lesions matters, the imaging modality also matters,” Dr. Melstrom said. There are limited data that fluorodeoxyglucose (FDG)-PET is more sensitive and more specific than a CT scan after neoadjuvant chemotherapy (Gastrointest Surg 2007;11[4]:472-478). FDGPET and CT sensitivity are lowered after neoadjuvant chemotherapy (Gastrointest Surg 2007;11[4]:472-478; Ann Surg Oncol 2009;16[5]:1247-1253). “Several factors contribute to this. Chemotherapy has the capability of inducing steatosis and steatohepatitis, and plus there is a decrease contrast differentiation between tumors and the background fatty liver,” she said. Dr. Melstrom said MRI is superior and may be able to compensate for these factors. “The data on MRI in this

Table 2. Imaging in Disappearing Colorectal Liver Metastases and Their Accuracy T Number of Patients

dCRLM With Complete Response CT

MRI

+IOUS

Median Follow-up (months)

Radiology. 2017;284(2):423-431

35%

78%

94%

J Surg Oncol. 2018;117(2):191-197

59%

85%

86%

HPB. 2018;20(8):708-714

51%

65%

92%

S Source: World J Surg Oncol. 2020;18(1):264. d dCRLM, disappearing colorectal liver metastases; IOUS, intraoperative ultrasound

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AUGUST 2021 / GENERAL SURGERY NEWS

setting is growing in recent years,” she said. A 2018 meta-analysis that systematically determined the diagnostic accuracy of multidetector row CT, gadoxetate disodium–enhanced MRI and PET/CT for diagnosing colorectal liver metastases demonstrated that PET/CT was quite specific, but MRI was superior in sensitivity than PET or CT and with better specificity than CT (Table 1) (J Magn Reson Imaging 2018;47[5]:1237-1250). If surgeons combine preoperative MRI planning with intraoperative use of ultrasound, they can have confidence that disappearing colorectal liver metastases may be a durable finding (Table 2) (World J Surg Oncol 2020;18[1]:264). Once the lesion has disappeared, what happens next? “This is addressed [in a series of eight studies]. Their findings were that recurrence could be as high as nearly 40% when MRI was added to the imaging modality,” Dr. Melstrom said. “However, it was upwards of 70% if imaging was limited to CT. In the more contemporary series, you can see that really in situ recurrence numbers are as low as 7% to 15% when you use MRI and intraoperative ultrasound.” Once the lesion has disappeared and left in situ, what impact is there on survival? In three studies, the range for three-year overall survival was 87% to 94%. And in a study by Tanaka et al, the median survival was 63 months (Ann Surg Oncol 2007;14[11]:3188-3194; J Gastrointest Surg 2010;14[11]:16911700; Ann Surg 2011;254[1]:114-118; Ann Surg 2009;250[6]:935-942). These same studies showed disease-free survival ranged from 16% to 64% at three years. “This data is quite compelling,” Dr. Melstrom said. A recent study aimed to assess management patterns of disappearing colorectal liver metastases from an international body of hepatobiliary surgeons (HPB 2021;23[4]:506-511). The survey involved 226 respondents representing 40 countries with a median age of 45 years. The vast majority of respondents were men, fellowship trained and worked at an academic or university hospital setting. Respondents commented that factors contributing to disappearing colorectal liver metastases not found in the OR included the location, presence of steatosis, small size of the lesions and surgeon experience with intraoperative ultrasound. “Of these, perhaps the only one we can improve is the intraoperative ultrasound, as we can’t change presentation and we can’t change biology,” Dr. Melstrom said. “In terms of imaging modalities used, 33% still utilized PET, and it was pretty evenly split as it pertains to MRI or CT; 47% to 45% used those modalities.” When those who were surveyed were asked how to proceed if the disappearing colorectal liver metastases were not

‘There is a reasonable chance that a disappearing lesion will not disa return, aand I will argue that if it does rreturn, there will remain treatment options. And lastly, treatm and most mo importantly, that if it does return, this small lesion will w not likely dictate the survival of your patient.’ s —Laleh Melstrom, MD, MS

identified in the OR, 48% elected for observation and 31% said resect if the presumed area is superficial. Of those electing for observation, 87% still believed that it was possible to treat the lesion if the disappearing liver metastases regrow. “In summary, I posit that MRI is the optimal modality to identify colorectal liver metastases before and after systemic therapy. Intraoperative maneuvers including ultrasound, localization, palpation and inspection are all useful in helping to visualize these lesions,” Dr. Melstrom said. “However, if you cannot, you can be rest assured that the rate of in situ recurrence can range from 7% to 15% with the above. And if you elect to observe these patients, rather than prophylactic resection or ablation, you are in good company with up to ■ 48% of your colleagues.”

Laleh Melstrom, MD, MS

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OPINION

GENERAL SURGERY NEWS / AUGUST 2021

Inflammation Everywhere continued from page 1

in edema and a net increase in plasma components to neutralize and phagocytize pathogens and foreign material. The associated innate immunity cytokines and other factors released are immediately available and non-intruder specific. As a medical student, I had memorized the five Latin diagnostics of inflammation: rubor, tumor, calor, dolor and functio laesa. As a doctor, I treated acute inflammation with antibiotics and, if purulent, with drainage.

for the underlying inflammatory cause of atherosclerosis. Type 1 diabetes is stated to be an autoimmune disease of pancreatic beta cells manifested by inflammation with eventual beta-cell destruction and cessation of insulin production. Most of the sci-

multiple inflammatory markers derived from or elicited by the gut, neurologic transmitters, adipocytes, the intestinal biomere and even bile salt composition. Similarities of inflammatory patterns in obesity, diabetes, hypertension and hyperlipidemia, as well as clinical kin-

Chronic Inflammation I was soon introduced, in my professional career, to the concept of chronic inflammation as the basis of certain lifelong diseases: rheumatoid arthritis, diverticulitis, asthma and others. The five diagnostic symptoms and signs of acute inflammation are, to some degree, present; however, they do not resolve and, in one manner or another, persist for a lifetime. In chronic inflammation, the dominant cell type is the macrophage, the vascular response is angiogenesis, and the immune response becomes more complex and antigen/antibody specific. Rather than resolution, chronic inflammation progresses to fibrosis, at times granulomatous, and tissue destruction with functional impairment. At first, we treated these diseases with analgesics and antipyretics, such as aspirin, subsequently with steroids, nonsteroidal anti-inflammatories, and more steroids. We rarely cure any of these afflictions; we treat the pathology, not the cause, and we hope to make the patient more comfortable.

Inflammatory Diseases By the turn of the century, the causative concept of inflammation became ubiquitous. Atherosclerosis no longer was considered primarily a passive disease of cholesterol lipid deposition engendering a foreign body response and plaque formation, but a continuously active process of pro-inflammatory low-density lipoprotein (LDL) excitation of the vascular endothelium, resulting in recruitment of monocytes and T cells, leading to the release of cytokines, proteases and vasoactive molecules. The immune mechanisms of the body counter with an anti-inflammatory response, which can be greatly aided by lowering the circulating LDL-cholesterol substrate. Thus, our lifestyle, diet, pharmaceutical and surgical lowering of LDL cholesterol markedly reduces the most crucial atherosclerotic raw material; it is not, however, curative therapy

Conceptualization of underlying inflammation in the primary chronic afflictions of humanity—obesity, diabetes, atherosclerosis, cancer—may be beneficial in our understanding of the processes involved and pathways for the evolution of new therapies. entific community postulates peripheral insulin resistance as the primary cause of type 2 diabetes, although there is solid evidence to support pancreatic islet cell dysfunction as the causative agent with insulin resistance being a secondary defense mechanism. The inflammation proponents of diabetes ideology cite the presence in both type 1 and type 2 diabetes of the cytokine proteins interferon, (IFN)-gamma, IFN-alpha and interleukin (IL)-1 beta, characteristically implicated in the pathogenesis of inflammation. The therapeutic use of anti-inflammatories with moderate palliative success is given as further evidence for the inflammatory nature of diabetes. Once obesity was accepted as a disease and the mechanisms of success of metabolic/bariatric surgery as neurohormonal and not simply caloric deprivation, obesity was considered a multifactorial inflammatory process. This reasoning was again based on the presence of

ship, gave rise to this cluster of pathology to be designated as the metabolic syndrome. Cancer, once characterized as a cellular mutation gone unchecked, with certain cancers founded on genetic (BRCA breast cancers) and environmental (smoking) causes, metamorphosed to being designated an inflammatory process. This concept is based on the belief that cellular proliferation alone does not cause cancer but that the mutation to malignancy is sustained by a receptive environment rich in inflammatory cells, growth factors, activated stroma and DNA-disruptive agents. Innate anti-inflammatory factors and immunity-triggered cancerkilling cells may become generated and try to annihilate the cancer. The outcome of this battle can destroy a patient’s cancer, result in a curable cancer by surgery and/or nonsurgical therapy, or evade current modes of intercession with a fatal outcome.

Agents of Inflammation and Anti-Inflammatories In addition to the presence of acute and chronic inflammation cellular elements (e.g., neutrophils, macrophages), there are a plethora of mediating agents involved in the inflammatory process. They consist of cytokines (i.e., signaling peptides) IL-1 beta, IL-6, tumor necrosis factor-alpha that cause receptor activation, which elicits intracellular signaling pathways including mitogen-activated protein kinase, nuclear factor kappa B and Janus kinase–signal transducer and activator of transcription pathways. There are at least five transcription factors, several serine/threonine protein kinases, many other cytokines, inflammatory proteins (e.g., C-reactive protein), haptoglobins, serum amyloid A, fibrinogen and 1-acid glycoprotein, as well as certain activated enzymes (e.g., inducible nitric oxide synthase), all involved in various aspects of the inflammation cascade. Numerous complex schemas of elucidation, progression, interaction and perpetuation of inflammation have been produced, primarily as a scholarly exercise and not too beneficial in the real world of patient care. In these schemas, there are also body-produced anti-inflammatories, such as the pituitary adrenocorticotropic hormone–stimulated adrenal glucocorticoids that counteract the proinflammatory agents and prevent an overwhelming inflammatory response and death of the individual. When this balance of chronicity fails, a fatal cytokine storm may ensue. In treating inflammation as a general or specific condition, in addition to pharmaceutical steroids, aspirin and nonsteroidal anti-inflammatories, certain foods with anti-inflammatory properties have been advocated, such as fish oils containing alpha and omega-3 fatty acids. Homeopathic preparations and questionable anti-inflammatory enemas have also found some popularity in the community.

What Does It All Mean? With regard to acute inflammation, except for extirpation of foreign bodies, our heritage from caveman days of draining abscesses has largely been supplanted by judicious use of antibiotics and image-assisted drainage by our radiology colleagues. Our current insight into chronic inflammation and antiinflammatories has, however, served us

IN THE NEWS

AUGUST 2021 / GENERAL SURGERY NEWS

PRODUC T ANNOUNCEMENT

MezLight Provides Bright, Focused Light well. The flagrant chronic inflammation of certain diseases has stimulated palliative, at times even curative, anti-inflammatory therapies. Conceptualization of underlying inflammation in the primary chronic afflictions of humanity—obesity, diabetes, atherosclerosis, cancer—may be beneficial in our understanding of the processes involved and pathways for the evolution of new therapies. Recently, inflammation has engendered great interest in explaining the clinical manifestations of COVID-19 and in treating them. The most susceptible individuals to contract severe COVID-19, requiring ICU admission, are the older patients and those with certain chronic disease states: cardiovascular, renal, diabetes, hypertension and obesity. This cohort harbors chronic inflammation and is more prone to exhibit a severe acute inflammatory response when infected with COVID-19, which may elicit a cytokine storm. Patients who recover from the acute infection can exhibit chronic inflammatory manifestations, such as myocarditis. Appreciation of the role of inflammation in the pathogenesis of COVID-19 has been responsible for instituting steroid anti-inflammatory therapy, which undoubtedly has saved many lives, shortened hospitalization for survivors and possibly dampened post– COVID-19 sequelae. Can inflammation, however, be as ubiquitous as current concepts would proclaim it to be? Is inflammation the progenitor of all diseases? I remember that in the 1980s the scientific world became enamored with the free radical nitric oxide because this substance seemed to be present in nearly every body response. Nitric oxide subsequently lost favorable enthusiasm and is rarely mentioned today by theorists of functional mechanisms. The identification of a multiplicity of agents, factors, processes, relationships, balances and imbalances does not equal understanding of causes and governing mechanisms. Although they both produce flames, smoke and heat, a forest fire is different from burning oil on top of water; a lightning strike is not the same as a gas leak near a flame. What we know today about inflammation is not grounds for complacency but stimulus for curiosity, thought and research. We have just started the journey of truly understand■ ing inflammation.

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OPINION

GENERAL SURGERY NEWS / AUGUST 2021

Dear Intern: What Would You Tell Yourself on Day 1? continued from page 1

basketball team’s locker room at halftime of a home game against a conference rival. I do not remember the score, but I know we were losing a game that we should have been winning. As if it happened yesterday, I still hear Coach McCoy’s voice. He should have been frustrated with us—he probably was—but I remember him calmly giving us life advice, ignoring the fact that we were struggling to make a free throw. He said, “This goes for life, too; if you just keep doing the right things, things will turn around and go for you. It might not be today, or next week or next year. But, if you just keep doing the right things, they will.” Long after my life as a competitive athlete ended, I held on to quotes like this one from my coaches. They were in my head during dedicated study for USMLE

During my fourth year of medical school, I relistened to some early episodes. I realized more of the answers were going to be helpful during intern year, so I started writing more of them down. It felt like they could stick with me during residency, in the same way that my coaches’ quotes had stuck for years. Writing a few of them down turned into writing all of them down. The final total was 96 answers from 85 guests. After compiling them, several themes emerged that are great insights for new trainees, as well as valuable reminders for surgeons at later stages of their careers. These are the general themes derived from the answers to the question, “If you could go back to your first day of intern year and tell yourself one thing, what would it be?”

is to learn. It is appropriate then that many of the surgeons gave advice related to learning. One takeaway was that the intern should learn all that they can, every day, from each patient. Another repeated idea was that spending time in the OR—even as a young trainee— is valuable. “Keep asking questions. Keep reading and keep being curious about your field. I think sometimes you lose sight of that during residency, where you become kind of tired of the grind, and you start to lose a little bit of the perspective of the love of what we do. I think it’s important to hold on to that.” —Dr. Al Beekley, Episode No. 64

4. Invest in relationships. Learning through participation in the care of surgical patients is the purpose of surgical residency programs, but such learning cannot occur without an entire team. That team is both diverse and expansive. Therefore, it is no surprise that many surgeons’ advice to their intern selves was focused on the importance of relationships with attendings, nurses and staff, co-residents, and patients. “Listen to the people around you. Almost everybody’s there to help you. And for crying out loud, ask for help whenever you need it.” —Dr. Michael Zinner, Episode No. 49

5. Find a balance.

It is no secret that surgical training requires grit and resilience, but be reassured that it gets better. There is a light at the end of the tunnel, and it is worth it. Step 1, a challenging transplant clerkship during my fourth year of medical school, the anxiety of a pandemic and difficult family situations. They will always stay with me, but I have also found more words of wisdom to hold on to that come from an increasingly relevant source: surgeons. When I started listening to the Behind the Knife (BTK) podcast, they had just begun publishing episodes. The structure and content of the show has evolved over time, but the early episodes focused on interviews with well-known surgeons with a consistent set of segments. The last segment was the “Final Five,” where the hosts asked their guests a set of questions that were designed to give listeners insight into the personalities of some of the leaders in surgery. The last question of the set of five was always my favorite. They asked, “If you could go back to your first day of intern year and tell yourself one thing, what would it be?” There were a few answers that stuck with me from the time I first heard them. One of them was from an episode with Dr. Thomas Scalea from Shock Trauma, in Baltimore. His advice to his former self was simple and blunt: “Don’t take yourself so goddamn seriously.” I wrote it down back in 2018 when I first heard it, because it was so relatable on a personal level for me. It felt good to know that even some of the most prolific surgeons had the same mental challenges as me.

1. Stay hopeful. Many surgeons wanted to tell their younger selves to be hopeful. Even the advice that ultimately fell into another category often still had an underlying tone of hopefulness. It is no secret that surgical training requires grit and resilience, but be reassured that it gets better. There is a light at the end of the tunnel, and it is worth it. “This too shall pass. It’s painful. The gap between what is expected from you and your skill set probably is never as wide for the rest of your career. Just have the long view.” —Dr. Hasan Alam, Episode No. 125

Relationships are important outside of surgical training, too. Actually, all of life outside of surgical training is important. Even the most prolific surgeons are people when they leave the hospital, too. Invest in your physical health, spend time with family and friends, and foster healthy habits outside the hospital. “You need to approach your profession with passion. You have to like it; if you don’t like it, you probably ought to find something else to do. But it can’t be everything you do. You have to balance your outside life with your professional life.” —Dr. John Devine, Episode No. 53

6. Just do your best. Some of the most valuable messages from senior surgeons did not necessarily fit into an overarching theme, but some of the ideas were related to working hard, taking responsibility and having integrity. “A major part was showing up, and showing up on time, and being ready to work.” —Dr. John Holcomb, Episode No. 7

3. Learn all you can.

The less serious answers by hosts, usually preceding or following a more sincere answer, have been appreciated, too. Looking back at the list of quotes, encouragement and helpfulness are the primary sentiments, but they were also fun. The founders of BTK are deeply thankful to the surgeons who have generously given their time to be guests on the podcast. I hope their messages can be sources of encouragement, inspiration and wisdom for the next generation of trainees. Over the last several years, the BTK podcast has grown and evolved to become an influential source in surgical education. You can find the episodes and much more by visiting www.behindtheknife.org. ■

Although there are a lot of other factors that get tossed into the conversation about surgical training, the bottom line is that the trainee’s primary purpose

—Dr. Gongola is PGY-1 in general surgery at the University of Kentucky in Lexington.

2. Relax. Closely related to the theme of hopefulness, there was another persistent message of the surgeons’ answers: Relax. This advice makes sense when considering that most highly successful surgeons are high achievers. They wanted their younger selves to know that they didn’t have to take themselves so seriously all the time. “Take a deep breath. Relax. Your heart is in the right place. You’re trying to do good things for people. You’ll be OK.” —Dr. Mark Welton, Episode No. 100

AUGUST 2021

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IN THE NEWS

GENERAL SURGERY NEWS / AUGUST 2021

Surgery for Diverticulitis: Who, When and How Still Up for Debate continued from page 1

become increasingly complex, said moderator Jason Patients who have more frequent attacks or disabling Hall, MD, MPH, an associate professor of surgery pain with attacks, or struggle with finances, work or and the co-director of the Dempsey Center for Diges- social life due to diverticulitis may benefit from surgery, tive Disorders at Boston University. “(Now) we often he said, adding that some patients want surgery because spend long, long minutes in the office, reviewing lots of they miss too many days of work from their disease or options for management with our patients.” receive repeated hospital bills related to this condition, For patients who are not acutely ill but have had at he said. He advised surgeons to take these quality-ofleast one episode of uncomplicated diverticulitis, sur- life issues into account. The decision to operate is “very geons should use patient-centered outcomes when much individualized based on the patient’s quality of deciding whether to operate, said Sean Langenfeld, life and priorities,” he said. MD, an associate professor and the chief of colon and “And when the time comes, sigmoid colectomy rectal surgery at the University of Nebraska Medi- works,” Dr. Langenfeld added, noting that the risk for cal Center, in Omaha. “In 2021, when you think about recurrent diverticulitis after colectomy is between 4% good reasons to operate, you can summarize it in three and 6%. Studies show patients’ quality of life improves words—quality of life,” he said. with surgery versus conservative management (Ann Elective sigmoid colectomies should be performed to Surg 2019;269[4]:612-620). improve quality of life rather than to prevent a future An ongoing randomized trial may yield more definhypothetical emergency, Dr. Langenfeld said. Quality of itive answers about the value of surgery in this populife should take priority over traditional onal objeclation. The COSMID study is a multicenter, tive metrics such as the number of attacks ttacks Ameri American trial designed to compare the or CT findings, he added. best medical care and sigmoid colectoThe standard of care for diverticcm my for patients who are asymptomulitis patients has changed markatic after recurrent uncomplicated edly over the past two decades. In diverticulitis or those who expethe past, surgery was recommendrience ongoing symptoms for ed for anyone who had a second more than three months after an attack of diverticulitis, or was index attack. younger than 50 years of age or “This is a fundamentally key immunocompromised at the first question for us as colorectal surepisode. In addition, for patientss ggeons as we see so many patients who did not have surgery, antibiottlik like this,” said co-principal investiics were given as standard, reflecting cting gato gator Thomas E. Read, MD, a profestso the belief that diverticulitis resultsor and the chief of gastrointestinal ed from microperforation and infecsurgery at the University of Florida ‘Diverticulitis has a very College of Medicine, in Gainesville. tion. However, in 2014, the ASCRS changed its guideline on surgery for Investigators plan to enroll 500 wide spectrum of disease diverticulitis, saying the decision to patients and assign them to surtype and severity, and operate should be individualized to gery or medical management with the patient and not based on the there is no one single rule a variety of tools including diet and number of attacks. exercise, fiber supplementation, proin terms of treatment.’ Recommendations are still evolvbiotics and rifamycin/mesalazine, ing, surgeons said during the session said principal investigator David —Dana M. Hayden, MD, MPH titled “Management of Diverticulitis. Flum, MD, MPH, a professor of Is There Anything We Were Taught surgery and the director of the UniThat Is True?” versity of Washington’s Surgical Outcomes Research Today, emerging evidence suggests that diverticuli- Center, in Seattle. All patients will complete the GIQLI tis arises from chronic inflammation of the gut and not at randomization and again at six, nine and 12 months infection (Gastroenterology 2019;156[5]:1282-1298.e1). after treatment. Moreover, recurrences after uncomplicated diverticulitis Investigators are looking to include patients treated are less frequent than previously estimated: Nonopera- at large and small hospitals, in rural and urban environtive management of acute uncomplicated diverticulitis ments, and a mix of academic and community practices. is successful in more than 95% of patients, Dr. Langen- Surgeons interested in participating are asked to contact feld said. This suggests that diverticulitis is not a pro- one of the investigators, Dr. Flum said. gressive disease, he noted. Fifteen hospitals in the United States are currently As understanding of diverticulitis evolved, surgery enrolling patients. The first results from the trial are became reserved for a more selected group of patients. expected after 2024. But exactly who and when and how are still up for Uncomplicated Diverticulitis: What to Do debate.

Uncomplicated Diverticulitis: When to Operate? Dr. Langenfeld said clinicians should use the Gastrointestinal Quality of Life Index (GIQLI)—a 36-point, validated health-related quality of life tool—to capture patient-centered outcomes like pain, appetite, reflux, social interaction and sexual function in patients with uncomplicated diverticulitis.

When You Don’t Operate The standard for medical therapy for patients with acute, uncomplicated diverticulitis also is in flux, said Fergal Fleming, MD, an associate professor of surgery and oncology at the University of Rochester, in New York. Contrary to traditional surgical dogma, not all nonsurgical patients require admission, antibiotics or medical therapy, he said. Two randomized controlled

trials—AVOD (Antibiotics in Acute, Uncomplicated Diverticulitis) and DIABOLO (Diverticulitis: AntiBiotics Or cLose Observation)—showed no significant differences in rates of recurrent diverticulitis, complicated diverticulitis, emergency colectomy, or elective colectomy for patients who received antibiotics or observation alone (Br J Surg 2012;99[4]:532-539; Br J Surg 2017;104[1]:52-61). “We need to move much more toward individualized medicalized therapy for patients with acute uncomplicated diverticulitis,” Dr. Fleming said. He noted that no conclusive data support clear fluids or a low-residue diet in patients with acute diverticulitis. According to the 2020 ASCRS clinical guideline, mesalamine was not found to reduce recurrent attacks in a meta-analysis of six randomized controlled trials, but rifaximin and fiber supplementation may reduce symptoms. Long-term use of nonsteroidal anti-inflammatory drugs should be avoided (Dis Colon Rectum 2020;63[6]:728-747).

Complicated Diverticulitis: Does It Always Require Surgery? Not all patients with complicated presentations of diverticulitis need surgery, said Dana M. Hayden, MD, MPH, the chief of colon and rectal surgery at Rush University Medical Center, in Chicago. Patients who are most likely to need surgery have larger abscesses, or have fistulas and strictures, which are more challenging and less effectively treated endoscopically, she said. Patients are less likely to require surgery after diverticular bleeding or if they have smaller abscesses associated with diverticulitis. “Diverticulitis has a very wide spectrum of disease type and severity, and there is no one single rule in terms of treatment,” Dr. Hayden said. When patients need emergency resection, surgeons should weigh technical variables such as ischemia of the bowel, patient factors, and surgeon and system factors, said Lynn M. O’Connor, MD, MPH, the chief of the Division of Colon and Rectal Surgery at Mercy Medical Center & St. Joseph Hospital, in Huntington, N,Y. “It’s really the context of the patient, as well as the surgeon’s experience that both will and should determine the choice of surgery,” she said. Evidence now supports primary anastomosis as the procedure of choice for stable patients with Hinchey III and IV classification. A 2019 meta-analysis that looked at the results of four trials comparing primary anastomosis with Hartmann’s procedure found that patients who underwent primary anastomosis were more likely to be stoma-free at 12 months after the initial surgery (risk ratio, 1.34; 95% CI, 1.16-1.54) and had a lower risk for complications following stoma reversal (Lancet Gastroenterol Hepatol 2019;4[8]:573-575). The authors also reported no differences in major postoperative complications or mortality at 12 months. However, primary anastomosis is rarely performed compared with Hartmann’s procedure. Of 2,729 patients in the United States who underwent emergency colectomy for diverticulitis between 2012 and 2016, 208 underwent a primary anastomosis (J Am Coll Surg 2019;229[1]:48-55). This year, the American Gastroenterological Association issued new guidelines on diverticulitis that highlighted the need for individualized treatment ■ (Gastroenterology 2021;160[3]:906-911.e1).

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General Surgery News: August 2021

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