Introduction

We are back in your inbox this month with a new MISS E-News!
This issue features an exit interview with outgoing President of the Americas Hernia Society (AHS) Dr. Benjamin Poulose, who is with the Division of General and Gastrointestinal Surgery at the Ohio State Wexner Medical Center in Ohio. I would like to extend a big thank you to Ben for taking the time to discuss the AHS’s challenges and accomplishments from the past year, as well as thoughts on the newly elected board, what’s on the horizon for the board and the society as a whole, the AHS COVID response, and more.
Last month’s issue featured an interview with MISS faculty members Robin Blackstone, Guy Voeller, Leena Khaitan, and Jaime Ponce. We discussed education—including the most effective tools in teaching and training our residents on multiple platforms—and whether surgical associations have adapted and grown accordingly, the biggest challenges in training residents, and social media as a tool or a weapon in teaching. If you missed it, that interview can be accessed here.
I hope you also enjoy this month’s article recommendations brought to you by Dr. Poulose!
We again include the most current best practice resources in our MISS E-News Resource Center.

**Don’t forget to link to the Virtual MISS 2020 Symposium here.**

Happy Thanksgiving from all of us at MISS and Medscape! Stay safe and thank you for reading!

–Colleen Hutchinson

Colleen: What were your biggest goals for this past year as Americas Hernia Society (AHS) President and how did the society fare regarding them?
Dr. Poulose: Our three biggest goals were the following:
1) Hire a new management services organization to help the AHS in its incredible growth phase and online presence. To meet this goal, we signed on with BSC Management who has done an incredible job.
2) Change the Annual Meeting from spring to fall. IN order to accomplish this, it required coordination with our European partners to move their meeting to spring. We successfully accomplished this then ran head on into COVID.
3) Explore adoption of the Abdominal Core Health concept. We published a manuscript regarding this idea in JAMA Surgery and initiated a brand migration to incorporate the concept in the identity of the AHS with the new logo.
 
Colleen: What are you most proud of during your tenure as AHS President?
Dr. Poulose: Our AHS Board, who worked through very difficult times over the past year and came out in a better place.

Colleen: What has been the biggest challenge of your AHS President tenure?
Dr. Poulose: The biggest challenge was guiding the organization forward from being a group of surgeons that like to talk about repairing hernias to a bona fide international organization with an innovative vision. Talking about fixing hernias is great—we all love to do it—but being a successful and respected international organization requires more than that.

Colleen: What are the strengths that the newly elected officers bring to the table and how do you foresee their impact?
Dr. Poulose: I think the newly elected officers and board members represent the exciting future of the AHS. They are a diverse group with, notably, two women. We also have the second woman (Dr. Ajita Prabhu) in the history of the AHS named to the Executive Council who will be on track to become AHS President. Additionally, we have excellent representation from our plastic surgery community and our international colleagues. Our leadership needs to become more diverse and reflective of our membership.

Colleen: What is exciting on the horizon for the newly elected officers?
Dr. Poulose: The future is bright! The organization is going to leap to new heights with multiple exciting initiatives, including the Web Information, Social media, and Education (WISE) initiative, and further incorporation of Abdominal Core Health into who we are as a society.
 
Colleen: How would you say the society responded to COVID?
Dr. Poulose: We honestly struggled with this. We didn’t want to be one of the many societies sending out a ‘thinking of you’ type of email to their membership during the initial surge. In retrospect, we could have helped come out with practical clinical guidance (especially on telehealth) or worked with larger societies (like the American College of Surgeons). But it was such a chaotic time and we decided it would be counterproductive to come out with inconsistent or contradictory messaging.

MISS E-News COVID Resource Center: Link to these!

IBC Hot Topics in Surgery Webinar: Battle of the Balloons—Watch here:
https://www.youtube.com/watch?v=6u295O6_tfw

The New England Journal of Medicine Article: Esophageal Motility Disorders and Gastroesophageal Reflux Disease
https://www.nejm.org/doi/full/10.1056/NEJMra2000328?query=featured_home

American College of Surgeons Bulletin Brief—November 10 Issue:
https://www.facs.org/publications/bulletin-brief/111020

General Surgery News Article: The Surgeon of the Future
https://www.generalsurgerynews.com

The Fight Continues: Contact Congress to Support Legislation Preventing Medicare Cuts! —Write to Congress here:
https://facs.quorum.us/campaign/29366/

Suggested Readings

Hernia

Article: Abdominal Core Health-A Needed Field in Surgery. Benjamin K Poulose, Gina L Adrales, Jeffrey E Janis. JAMA 2020 Mar 1;155(3):185-186. doi: 10.1001/jamasurg.2019.
https://pubmed.ncbi.nlm.nih.gov/31851303/

Dr. Benjamin Poulose: We thought carefully about the concept of Abdominal Core Health, how it might enhance our identity, and how it could open up new avenues not available to us as hernia surgeons.

General

Article: In Defense of Peer Review. Surg Innov. 2020 Apr;27(2):133-135. doi: 10.1177/1553350620902349. Epub 2020 Feb 1. Prabhu A.
https://pubmed.ncbi.nlm.nih.gov/32008464/

Dr. Benjamin Poulose: Peer review is a critical part of our scientific validation process. That said, unhealthy competition can also play out in peer review-especially when the reviewer is typically blinded. I believe that peer reviewed work can coexist with the many other means of information dissemination coming online.

Introduction

This month’s issue features an interview with our MISS 2020 Faculty Robin Blackstone, Guy Voeller, Leena Khaitan, and Jaime Ponce. These thought leaders discuss various topics involving education—including the most effective tools in teaching and training our residents on multiple platforms—and whether surgical associations have adapted and grown accordingly, the biggest challenges in training residents, and social media as a tool or a weapon in teaching.
I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders in surgical research and innovation. Thank you to these doctors for sharing their thoughts and opinions with us, and also to all of this month’s contributors!

Happy Halloween from all of us at MISS!

–Colleen Hutchinson

What are the most effective tools in teaching and training in your area of surgery today, in a climate and environment where there are multiple surgical approaches to learn, and what role does simulation play?
Dr. Blackstone: Currently we are still doing essentially case-by-case, one-on-one mentoring for operative skills. As it always has in surgery, this introduces valuable insights and technical instruction; however, it also introduces inconsistency in both approach and technique. Simulation is improving but is not nearly where it will need to be to provide more depth to training. It tends to be the “starter” kit for individual skills.

Dr. Ponce: I think today it is more important than ever that new trainees get exposed to different approaches and techniques. If accessible, direct exposure to experts in those different methods is the best way of learning and adopting them. If experts are not readily available, certainly external rotations or simulators are the other options. I think the simulators’ capabilities nowadays are very real and very useful to shorten the learning curve for operating in real patients.

Dr. Voeller: Please note that the answers to all these questions are the same. Training for all medical personnel has suffered. Nurses are getting their “doctorates” online and telemedicine is all the rage. EMR is simple copy and paste and has nothing to do with patient care and instead has everything to do with billing and “quality metrics.”
Simulation is not surgery. The stress is not the same, but with training of surgery residents as poor as it is today, it is all we have left. With all of the “questionable” (I have another word I use in private communications) regulations that the ACGME has foisted on surgical training over the past 10 years, the trainees and ultimately their patients are paying the price of these damaging and profession-destroying rules. The most effective way to learn to do surgery is to live at the hospital and operate, operate, and then operate some more. That is why it was called a “residency.” Our forefathers knew how hard this profession is and what it takes to get good enough where you don’t harm people. They knew you had to dedicate every waking minute to the profession.
With the new training “methods,” it is no longer a “residency.” It is a shell of what it used to be. We have made these young people believe that you can have it all and don’t have to sacrifice quality of life. This is not true. There is only one life that matters and that is the patient’s life. I don’t care if it is open surgery, straight sticks laparoscopy, or robotic laparoscopic surgery… the ONLY way to get good at these “multiple surgical approaches” as you call them is to do them all the time. That means total dedication and nothing less. The fact that there are now more “surgical approaches” to learn and we have work-hour restrictions and other craziness means the training needs to be longer. Simulation can NEVER create the real world; that is why it is called “simulation.” It creates a false sense that you know what you are doing when you actually do not.

Dr. Khaitan: Multiple tools exist, and it somewhat depends on the incoming skillset of the surgeon when learning a new skill. This current pandemic has also affected how this teaching is disseminated. Currently online webinars and discussions are a great way to get introduced to new technologies. These can be done through societies, social media groups, and industry. Hands-on courses were also a great asset, but with COVID we have to be more creative as this is harder to do now. So, simulation is a key part of this. Surgeons can be coached virtually. Also, there are new technologies where a deliverable simulator can be sent to the learner and then he/she uses the hands-on tool while being coached remotely. This is a very new approach and has been adopted for hernia, for example, by SAGES.

Have surgical associations adapted and grown accordingly?
Dr. Ponce: I think some societies are trying to stay ahead. Ideally, the professional societies need to invest in education, not only by lectures and skill labs, but in real training centers with simulators that can get the input of field experts and allow them not only to improve educational offerings, but also to work with the industry to improve the simulators’ technology and content.

Dr. Khaitan: Yes, the online offerings for zoom's, webinars, interactive courses have exploded over the last year.

Dr. Blackstone: Actually, the society that—to my mind—has played the most consistent role in developing crucial adjuncts to training is SAGES. Early on, they saw a need to develop standardized curricula around energy use, for instance, and laparoscopic skill sets, and the society has provided tremendous value through the now required instruction.

Dr. Voeller: Somewhat but not significantly. They, like training programs, are trying to come to grips with the profession-destroying regulations of the ACGME and new technologies but it is not easy to do. With the COVID mess, it is even more challenging. They are guilty of perpetuating the educational downfall of the trainees by bending to the will of the masses and not taking a stance on things that matter regarding training. The ACS is a perfect example. They are more interested in the politically correct social issues and societal “norms” and are so out of touch with the practicing surgeon.

What is the biggest challenge today in training residents?
Dr. Blackstone: Variation and low case volume. Truly gifted surgical residents seem to be able to be great no matter what the environment; however, the variability in teaching and training seems to have a greater impact on residents without strong native skills. These residents often get left behind—they don’t get to operate as often or get the same opportunity for independent work. There is also a great deal of pressure on attending surgeons to have “perfect” surgical outcomes, which may diminish a surgeon’s willingness to let a resident operate who he/she perceives as not being as skilled. Identifying these residents and building a matrix of support and training to maximize their skills is crucial. The role of mentoring/sponsorship is also a big factor in resident development.

Dr. Ponce: There are some limitations in training time (restricted hours), in mandatory supervision (less autonomy), and in some programs, the lack of the technology to improve the learning curve.

Dr. Voeller: The biggest challenge is training them. With the profession destroying work hour restrictions and the politically correct environment of academia it is impossible. We also have the “inmates running the asylum” so to speak in that the trainees, who have no idea what they are doing, yet are telling the training programs what they want and how to train them. The training programs in surgery should be focused on one thing—training young men and women how to operate on humans and not harm or kill them. This is not the case. Grand Rounds are now spent on Equity and Diversity topics and other things that, while important, have nothing to do with being able to operate on people properly.
At morbidity and mortality conferences, residents are not criticized, and the atmosphere is one of an “it will be ok” kind of approach. We are failing these young people by how we are now “training” them, and that is why so many do fellowships. They know they are not prepared for the real world. The disconnect between academia and the real world has never been bigger and more damaging to training. This is why you are seeing more private surgical training programs beginning, because hospitals realize what is going on now is not developing surgeons who are ready to take on real-world challenges.

Dr. Khaitan: Training residents is as fun as it always was. I think the training part continues to evolve with the addition of simulation labs, local teaching, and online lectures. I think the harder part is getting quality residents in the program, as so much of the interview process will be virtual this year.

For practicing general surgeons who seek to learn new techniques and procedures, has social media become more of an educational tool or a weapon?
Dr. Voeller: Both. Social media has become more of an educational tool, while at the same time becoming a risky form of learning. While ideas can be shared quickly, sometimes it is superficially done and the checks and balances are not there. Practicing surgeons need better avenues to stay current, and company sponsored training—while criticized by many—is a very important way to help practicing surgeons stay current.

Dr. Khaitan: Absolutely. Social media is a great way to learn from others, review challenging cases, and get multiple opinions. For learning new techniques, it is helpful and a great way to get exposed to a new technique. But this cannot replace the hands-on training that is needed for more complex procedures.

Dr. Ponce: I think social media, used by professional organizations, actually has become a useful tool for practicing surgeons. It may need to be more closely monitored. But certainly, what it is not monitored is the independent sharing of “how I do it” videos and forums of questions in social media. Even though some of these social media resources are very valuable, easily accessible, and inexpensive, we sure sometimes need a little bit of vetting. But the future will continue to be driven by the easiness of social media and the web to obtain some information.

Dr. Blackstone: "Social media” is a broad term. Tweets, Facebook, LinkedIn, Doximity, etc., can be very interesting, raising awareness of specific techniques or new data. New surgical education platforms such as that offered by the AIS Channel are delivering high-quality information in a fun and exciting way. No matter what platform surgeons are using, bias may be introduced by the nature of the media.

MISS E-News COVID Resource Center: Link to these!

American College of Surgeons Recommendations Concerning Surgery Amid the COVID-19 Pandemic Resurgence:
https://www.facs.org/publications/bulletin-brief/102720/clinical#covid

The New England Journal of Medicine Editorial Perspective: Evaluating and Deploying Covid-19 Vaccines — The Importance of Transparency, Scientific Integrity, and Public Trust
https://www.nejm.org/doi/full/10.1056/NEJMp2026393?query=featured_home

American College of Surgeons Bulletin Brief—October 27 Issue:
https://www.facs.org/publications/bulletin-brief/102720

2020 Medical Innovation Summit: Has COVID-19 Extinguished Innovation? Not If These Robotic Startups Can Help It. November 3, 2020 1:00 PM – 2:00 PM EST. Register here:
https://www.eventbrite.com

IBC Hot Topics in Surgery Webinar: Lexington Stapler Sleeve Gastrectomy—Watch here:
https://www.youtube.com/watch?v=h-ywyhX7HDo

Suggested Readings

Colon

Article: taTME can be safe and efficacious. Steven D. Wexner. Obesity Surgery (2020) 30:707–713.
Gastroenterol Rep (Oxf). 2020 Feb 21;8(1):1-4. doi: 10.1093/gastro/goaa001.
https://pubmed.ncbi.nlm.nih.gov/32104580/

Dr. Steven Wexner: I was privileged to coauthor an editorial in Gastroenterology Report with Liang Kang, Patricia Sylla, Sam Atallah, Massaki Ito, and Jian-Ping Wang. Our editorial reiterates the importance of training, volume, and experience in obtaining oncologically optimal outcomes following taTME. Quite simply it appears that high per surgeon case volume and multidisciplinary team efforts are essential prerequisites to achieve these outcomes. I am optimistic that the American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer will help us achieve these goals.

General

Article: Using databases to improve outcomes in rectal cancer surgery.
https://www.linkedin.com

(An Expert Commentary on: A NSQIP analysis of trends in surgical outcomes for rectal cancer: What can we improve upon? Am J Surg. 2020 Aug;220(2):401-407. doi: 10.1016/j.amjsurg.2020.01.004. Epub 2020 Jan 10. Steven D. Wexner.
https://pubmed.ncbi.nlm.nih.gov/31964524/)

Dr. Steven Wexner: This article assessed patients with colorectal cancer who had data reported in the ACS National Surgical Quality Improvement program (NSQIP) database. We were able to identify 34,000 patients who we divided into abdominal colonic and pelvic rectal cohorts. Several interesting findings emerged including the fact that patients in the latter group were more likely to have suffered major complications than were patients in the former group. In addition, there was an overall significant reduction in the length of stay perhaps due to the increased prevalence of minimally invasive surgery and/or enhanced recovery protocols. Many of these important data were unfortunately lacking within the ACS NSQIP database highlighting the need for constant review and updating of data fields in order to ensure that the ACS NSQIP database represents the most comprehensive clinically relevant data repository for patients undergoing colorectal cancer surgery.

Introduction

This is a special tribute issue that is dedicated to the memory of Harvey J. Sugerman. When I first started in medical publishing, I was the editor of a new bariatric journal. I wore many hats, managing all steps of publication from editorial board development to content acquisition and issue planning right down to the graphic design and printing of the journal! As such, I oversaw inclusion of ads as well as the peer-reviewed articles. My first experience with Harvey Sugerman was both scary and enlightening. He called and left a message, and my heart dropped when I heard this giant of bariatric surgery on my voice mail. We finally connected, and he took me to task for including an Allergan ad on the Lap-Band, explaining sternly to me—insisting actually—that the ad MUST be removed from all future issues, as its claims in the small print were not published. This was a tall order (especially from someone who was not our Clinical Editor), about removal of an ad from a corporate titan in our newly launched journal! But this was also a lesson to me on journalistic integrity and the importance of vetting everything you publish—not just the peer-reviewed content. That lesson and his constant fostering of ethics in journalism (that he pushed people to adhere to) have stayed with me and were a critical help particularly when I started my own company and became an independent publisher. I learned to not only thoroughly vet what I publish, but also to be extremely careful, thoughtful, and critical of any project on which I am asked to collaborate, and cautious regarding those with whom I choose to partner. I owe him a great debt for this influence, and I wish I could have told him that.
Harvey Sugerman had impact on so many—and on not just a surgeon/clinical level, but on personal, research, and academic levels as well. Please read here as some of our MISS faculty share their thoughts on Harvey J. Sugerman, MD.

Stay safe and thank you for reading!

–Colleen Hutchinson

MISS Special Issue: A Tribute to Harvey J. Sugerman, MD

Is there a specific publication/article/manuscript that comes to mind when you think of Harvey, in his role as surgeon author, mentor, or editor?

Dr. Michael Schweitzer: I still quote this study today and use it in my practice, “A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss” (Sugerman HJ, et al. Am J Surg. 1995 Jan;169(1):91-6; discussion 96-7; https://pubmed.ncbi.nlm.nih.gov/7818005/). It is a multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric bypass-induced rapid weight loss.

Dr. Corrigan McBride: Many people will quote Harvey’s randomized trial of vertical banded gastroplasty versus gastric bypass. But just a few weeks ago, surgical oncologists published a study about ursodiol after gastrectomy to prevent cholelithiasis, and I was amazed. Dr. Sugarman did this study in 1995. He was a visionary, and other disciplines are now just learning and repeating his work.

Dr. Raul Rosenthal: His Ed Mason lecture. He showed how he battled adversity in life and despite all hurdles, he still came out victorious.

Dr. Jaime Ponce: There were several memorable times working with Harvey in research and publishing. During one of my first oral paper presentations in the ASBS plenary session, I presented our center’s experience with the laparoscopic adjustable gastric band (LAGB) and diabetes/hypertension, and he was very critical, as you can imagine. But he took the time to listen and make extensive and constructive comments. Then I followed him in the ASMBS Centers of Excellence Bariatric Surgery Review Committee as a Chair and worked alongside him, learning how to run a sometimes-difficult meeting among peers.
I learned as well from how detail-oriented and ethical he was with our SOARD journal integrity, when I worked with him to review claims in ads placed in the journal. Probably the most impactful thing I experienced from Harvey was—as critical as he has been at times, he wrote me an email stating that I did a great job with my Presidential Address and President term with ASMBS. It meant a lot to me, as he was a role model for leadership and organization.

Dr. Marina Kurian: The article on sweets and non-sweet eaters was really a landmark paper to understand patient selection and outcomes. He always pushed the ASMBS to be data-driven and elevated bariatric surgery to be a field of surgical excellence and improved patient outcomes.

Dr. Samer Mattar: I think the most important role that Harvey played was as advocate and protector of patients. He dedicated his entire career to helping distraught, downtrodden, and disenfranchised patients with obesity, always stepping up to defend them at regional and national forums and in the nation's capital. He was one of the few surgeons to refuse to get on the LAGB bandwagon and strongly criticized it during the FDA trial—and boy, has anyone's opinion ever been more prescient?

Dr. Phil Schauer: So many Sugerman contributions to choose from! I agree with Raul, his Mason lecture “My Journey” encapsulates his entire life and is a must see. He had “many ups and downs, but mostly ups and would not change a thing.” Do yourself a favor and watch it here: https://www.youtube.com/watch?v=8_1Ugr1Vp1k. His vertical banded gastroplasty versus gastric bypass randomized controlled trial (RCT) taught me the value of an RCT, which has been my obsession ever since.

What has Harvey’s impact been on you (personally or professionally)?

Dr. Michael Schweitzer: Harvey was the one who mentored me on bariatric surgery and life.
Harvey hired me as junior faculty at Medical College of Virginia in 1997. I still remember Harvey teaching me my first open gastric bypass like it was yesterday. It was, of course, a post-liver transplant patient who (unbeknownst to us) had a few posterior gastric varices that audibly bled a liter before the stapler could be removed. He calmly applied pressure and stopped the bleeding. The patient did well after that.
I humbly got to teach Harvey his first laparoscopic gastric bypass a couple of years later. He was so ecstatic that he immediately had the patient featured in USA Today before the wounds were even healed. His energy for both surgery and research was contagious.
When Harvey went to a meeting, covering his service was a tall order since Harvey never turned away a patient, no matter how ill. This included complex bariatric, Crohn’s, and ulcerative colitis patients.
Today, when a patient asks me why I perform bariatric surgery, I immediately quote what Harvey taught me, and it always brings a smile to the patient’s face because it is the perfect answer. The perfect answer actually comprises a long talk with the patient, but the main thrust of that talk is that I do it for their health. I discuss how comorbidities improve with gastric bypass, personalizing it to his/her specific comorbidities. I share that I used to perform Nissen fundoplications for GERD, wrap leg ulcers in an Unna boots, and all kinds of other treatments, but explained that these measures never treated the problem at hand’s underlying cause—obesity. So those treatments would fail in the morbidly obese. This answer always resonates with patients, because the patient who asks that question is never one who wants surgery for cosmetic reasons. It was Harvey who taught me this; he kept great data and proved to me that medical comorbidities are improved with gastric bypass (in the 1990s).
I was extremely grateful to have Harvey mentor me. He was wonderful. I miss him already……

Dr. Walter Pories: Thank you for the opportunity to add my tribute to one of the true giants, Harvey Sugerman. I do not need to reiterate my admiration for his contributions as a surgeon, as a scientist and as one of the moving leaders in our specialty.
Instead, let me share an anecdote that underscores his dedication, his originality and tenacity. In the 1990s, surgeons adopted the gastric bypasses with enthusiasm. After the dismal failure of the intestinal bypasses, here was a new operation that, at least judging from the diagrams, shouldn’t be any more challenging than other gastric procedures. The results were dismal with mortality rates over 10%, even in some prominent hospitals.
The poor results were the major concerns at the meeting of the ASBS in 2004, and three of us in the leadership, Alan Wittgrove, Ken Champion and I decided that a Centers of Excellence approach might offer an answer. The creation of that led to a remarkable improvement in safety with 90-day mortality rates down to less than one percent. Even so, the insurance companies would not extend coverage, citing not only the previous bad results but also the increasing rate and prevalence of obesity. We were totally stymied until Harvey suggested that if we managed to convince Medicare to include bariatric surgery as a standard of care, the private carriers would follow. Not a chance, we said, but Harvey, as you well know, was like a dog with a bone. After some weeks of diligent searching, he located a surgeon, an ophthalmologist no less, who worked in the basement of the agency and then dragged me to Washington to get this bureaucrat on board. Harvey was convincing until he was asked what the rules should be for eligibility. Harvey did not stop for a minute, but said that patients should qualify if they have a BMI ≥40 or a BMI≥ 35 with serious comorbidities. On our way home, I asked him how he got those numbers and he admitted that he made them up on the spot. They are still with us today. By 2006, bariatric surgery was approved by Medicare and most large carriers.
We will miss this courageous, fallen comrade who contributed so much. And we cannot offer this tribute without also recognizing that he could never have accomplished these great advances without Betsy, his wife, companion, friend and nurse.

Dr. Raul Rosenthal: I worked alongside Harvey as Co-Editor-in-Chief of SOARD for the last three years and learned how to be a better academician. Harvey, was, however, a role model and mentor for most bariatric surgeons worldwide, including myself.

Dr. Ninh Nguyen: I first met Harvey when he was the discussant on one of my very first publications on laparoscopic gastric bypass. (Nguyen NT, Ho HS, Palmer LS, Wolfe BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg 2000;191:149-155.) This study was presented at the ACS in 1999, which was the early period when data were just coming out regarding the procedure. There was skepticism in this new minimally invasive technique, including from Harvey. As a true scientist and pioneer in the field of bariatric surgery, Harvey was critical of the new technique (rightly so) and pointed out many of the limitations of the technique and the retrospective nature of our study. All of his points were spot on and his words of wisdom pushed me even further to perform a randomized trial, which we completed and presented at the American Surgical Association in 2001. Harvey is someone who pushes you to make you better. It's called tough love and we are all in debt to his contribution to our field.  

Dr. Corrigan McBride: I was fortunate enough to be the second MIS bariatric fellow that Dr. Sugarman trained, and that year changed the entire focus of my career from being an MIS general surgeon to being a bariatric surgeon. He was in the final years of his operative career then, yet he was learning and mastering the minimally invasive approach. This showed me that we always have to be open to learning new things and new approaches if it is the best thing for our patients.

Dr. Samer Mattar: Harvey gave me candid and direct advice at many stages of my career. I remember many years ago approaching him at a national meeting to ask if I could be on the Editorial Board of SOARD, which he had just launched. He quietly turned to me and said it was too early to consider that, because I was not experienced enough. A few years later, I did receive an invitation from him to sit on the Editorial Board, and he subsequently "promoted" me to Associate Editor (CME editor). As always, he was correct in making me wait until I accrued more experience.
Harvey was astute and fair, never missing an opportunity to give credit (and grief) to members of the Editorial Board. He was a true leader and mentor. He taught me to be patient and prove myself before expecting acknowledgement and career advancement. I also remember his kindness on another occasion when he asked me at a meeting to join him for dinner. I readily agreed, thinking that I would be joining a large group of colleagues, or friends who admired Harvey, but was surprised that it was just the two of us. He was genuinely interested in learning about my background and my views of the current state of bariatric surgery. That was so flattering and humbling.

Dr. Jaime Ponce: Harvey was always committed to his work. He was not shy to share his viewpoint or to tell me when he disagreed. I learned from his leadership, participation, and commitment.

Dr. Daniel B. Jones: Dr. Sugerman corralled a group of pioneering surgeons to advance the science of obesity and establish the field of bariatric and metabolic surgery.

Dr. John Morton: Dr. Sugerman's approval meant the world to me—I felt I had arrived in style. I admired his wide breadth of interests and his willingness to speak up, no matter the consequences. He was strong and brave in all—adversity, personal, clinical, and academic. I will miss him, and the world is poorer without him.

Dr. Marina Kurian: Professionally, Harvey always pushed you to offer your best to your colleagues and to your patients. He took on high-risk cases to help patients, and those discussions I had with him were impactful.

Dr. Robin Blackstone: Harvey Sugerman impacted metabolic and bariatric surgery in many ways, including scientifically and politically. His most fundamental non-academic contribution was to expand the inclusion of women in the executive leadership of ASMBS when he nominated and supported me to become the first woman President of our Society. That one act opened the door to diversity and inclusion within our society, established the opportunity for collaboration with the American College of Surgeons on quality through MBSAQIP, and helped establish metabolic/bariatric surgery as a fully accepted and endorsed part of American surgery. His foresight and vision were remarkable.

Dr. Matthew Hutter: Harvey was an amazing man and is an inspiration to us all. To me, Harvey exemplifies how an individual can have a profound impact on countless patients and an entire field of medicine through dogged determination, indefatigable energy, remarkable resiliency, and a genuine inquisitiveness. We all should look closely at our field and think critically about what needs to be done to make surgery better for our patients and ask, “What would Harvey have done?” and then do it. No matter how challenging it might be. That is what Harvey did his whole life. He will be greatly missed.

Dr. Scott Shikora: I never worked directly with Dr. Sugerman but knew him well via our mutual involvement in the leadership of the ASMBS. I was an executive council member during his presidency. Harvey had a significant role in improving the field of bariatric surgery not just for his benefit or that of a few, but instead for all bariatric clinicians and their patients. His efforts and influence ran the gamut from leadership, advocacy, research, and education.
There may never again be a person who so greatly improved an entire medical discipline.  He will be missed, but not forgotten.

Dr. Phil Schauer: Harvey was a quintessential Surgeon, Scientist, Educator, and Leader. Beyond that he was a good personal friend, mentor, and loyal MISS faculty member. He was very influential to me personally in pursuing an academic career focusing on bariatric surgery. Way back in the 1980s, I first heard him, already a doyen of bariatric surgery, speak about bariatric surgery at Surgical Grand Rounds at UT San Antonio. At that time, I never imagined I would spend my entire carrier endeavoring to make a contribution to what we now call metabolic surgery. But his lecture planted a seed of interest that was destined to sprout in my future. Later, after finishing fellowship in advanced laparoscopy, and dazzled by what Alan Wittgrove was doing with laparoscopic gastric bypass, I plunged into bariatric surgery as a major career focus shortly after joining the faculty at the University of Pittsburgh. To gain credibility for pursuing such a career, I sought support from Harvey. He became a life-long mentor to me as he has to many surgeons. He had all attributes of a great mentor – very encouraging, critical at times, and frankly inspiring. On the other hand, Harvey never let friendship and admiration get in the way of a stiff reprimand! “What’s good for the goose is good for the gander,” he would say. After missing a couple of SOARD editorial review deadlines, he fired me from the board. He eventually let me back in, but I do think I hold the record for being fired at least times by Harvey!  

One final but important comment apropos to MISS is that Harvey Sugerman deserves credit for the initial idea of MISS! Around 1999 or 2000, during a faculty dinner of one or our bariatric surgery training courses at University of Pittsburgh, Harvey, an avid skier, said, “Why don’t you have a bariatric teaching conference at a ski resort?” Hence, MISS was born in the winter of 2001. As many of you know, the first 10 years of MISS were at world class ski resorts until we were forced to change venue (that’s another story!). Harvey was a regular and dedicated faculty member at MISS—so generous sharing his knowledge and wisdom. One year, he even participated in MISS right after neck surgery! See photos for proof!

Pardon the pun, but we really are going to miss Harvey at MISS! God bless you, Harvey, and thanks for your friendship. I think we can all say that we were privileged to have known and worked with Harvey Sugerman!

Introduction

We are back in your inbox this month with a new MISS E-News!

This issue features an interview with Dr. Ajita Prabhu, who is with the Department of Surgery at Cleveland Clinic, Ohio. We are excited to introduce Dr. Prabhu additionally in this issue as the newly elected Treasurer serving on the Executive Council of the Americas Hernia Society. Congratulations, Dr. Prabhu! Ajita and I discuss two recent publications of hers—the first is a recent article in Surgical Innovation titled “In Defense of Peer Review”, and the second is an editorial she had published in General Surgery News titled “Quantity Over Quality in Hernia Data: It’s Time to Up Our Game.” Dr. Prabhu adroitly identifies the strengths and weaknesses of both educational resources and provides an insightful, balanced perspective on utilization of both. Special thanks to Dr. Prabhu for devoting the time to conduct this interview and discuss the ever-evolving roles of peer review medical literature and social media as a vehicle for surgical education.

The August issue featured an interview with MISS faculty Leena Khaitan, Bradley Davis, Phil Schauer, Robin Blackstone, and John Dixon, who discussed the role of AI within healthcare and specifically within minimally invasive surgery. If you missed it, that interview can be accessed here.

We again include the most current best practice resources in our MISS E-News Resource Center.

**Don’t forget to link to the Virtual MISS 2020 Symposium here.**

Stay safe and thank you for reading!

–Colleen Hutchinson

Interview with Dr. Ajita Prabhu

Colleen: You recently published an editorial, “Quantity Over Quality in Hernia Data: It’s Time to Up Our Game,” in General Surgery News. Some surgeons interpreted this piece as a war on social media, yet that interpretation is not supported by the content of the article. What is the understanding you want readers to take away from your editorial?
Dr. Prabhu: It is well-established that much of the commentary on social media websites is derived from skimming articles prior to sharing them and commenting on them, as opposed to thoroughly reading them and critically analyzing their content (Anspach, Research & Politics, 2019). I suspect that practice drove a lot of the narrative related to that article. In the editorial, the term “quantity” refers to the voluminous amount of peer-reviewed surgical literature that has failed to answer some of our most pressing questions in hernia surgery.
The editorial is meant as a call to action for all of us to contribute in a more meaningful way, whether it be through registry participation, or the onerous contribution of well-designed prospective clinical trials. The article is equally critical of both peer review and social media. I daresay we can all unite in the statement that we have a long way to go in truly understanding hernia disease.

Colleen: Given your new role at Americas Hernia Society (AHS), you have a unique perspective on females in leadership roles in hernia surgery. How would you characterize the current state?
Dr. Prabhu: As the newly appointed treasurer of AHS, I’m pleased to have the honor of becoming the second woman on the Executive Council. The organization has been working on taking meaningful steps towards having a more balanced representation of its members at the leadership level, and also to create more opportunities for its membership at large. Still, we have a long way to go in terms of inclusivity, which currently is a mission and not a requisite. Getting there will require a sustained effort on behalf of those who are underrepresented, but will also require a frame shift from those who haven’t been affected. Everyone has a part to play in this.

Colleen: What are your hopes for AHS this coming year?
Dr. Prabhu: For the coming year, I’d like to see the AHS carry forth some of its great work, particularly at the resident member level. Every society needs to recruit and support young talent to stay current, and also to provide a path forward. We need to focus on getting our young surgeons not only to become members, but to have a role in the future direction of the society. We have made great strides in this area in the past few years, and we will need to maintain that effort moving forward.

Colleen: In your recent article in Surgical Innovation, you speak on some drawbacks of both peer-reviewed medical literature and social media and state: “While social media forums can offer an easily accessible and convenient resource to busy physicians, it would be a mistake, to say the least, to allow these to replace evidence-based medicine as the foundation upon which we offer care to our patients.”
You also state: “It [peer review] is beleaguered by an inundation of submissions of varying quality, reviews which are not compensated and potentially (therefore) of varying quality, significant lag time in the transmission of new and significant information, and potential for bias—whether on the part of the author, the editor, and/or the reviewer. There is also an acknowledged high rate of medical reversals, where practices once standardized based on evidence are later debunked by newer evidence, the result of which is a slow erosion of the credibility of peer-reviewed research at its core. Some detractors also submit that many submissions are disingenuous in their intent to begin with, even going so far as to suggest the underlying agenda is self-promotion and/or financial gain.”
In the evolution of research, publishing, and information sharing in our digital age, how do you see the role of peer-reviewed medical literature and the role of social media—both with their faults and neither mutually exclusive—shaping modern medicine and education?
Dr. Prabhu: In a healthy surgical ecosystem, both peer-reviewed medical literature and social media should have their relative and meaningful contributions. One cannot and should not replace the other. Surgeons ideally should work together and respect each other’s contributions. Both methods of information-sharing have some glaring limitations, and both also have a lot to add. Many of the surgeons participating in the online social media forums are incredibly talented and innovative, and when the system is productive, it serves as an invaluable resource for sharing new techniques, coaching/mentoring younger or less experienced surgeons, and advising or help troubleshooting for those in need of support. Many of those who contribute to the Facebook groups are doing a great job of leveraging their platform to unify the surgical community, even going so far as to live-stream events and conferences. There are also plenty of participants whose contributions are damaging or unhelpful, particularly towards participants who express a difference of opinion. That said, in an ideally balanced system, new techniques would get introduced in these types of social media forums, surgeons could continue to learn from each other regarding the execution of the operations, and then the peer-review system should be engaged to help vet the innovations and give them further context. This essentially completes the cycle. It’s a slow process, and new concepts and technology need to be studied and re-studied over time to determine their ultimate roles. Just like social media, peer review is not perfect by a long shot. However, it provides a balance for the large volumes of social media content which are often not well vetted and heavily rely on anecdote. Randomized controlled trials are one aspect of peer-reviewed literature which are only able to truly answer specific questions usually of narrow scope, and still there are often design flaws, bias, etc. that can limit the interpretation or applicability of the findings. That’s why registry data (really population-based data) is so important and can help to generate hypotheses but also serve as a space in which to follow the outcomes of interventions with specificity. A step in the right direction would be for contributors of both modalities to acknowledge the strengths and weaknesses of their platforms in a dispassionate manner, and to accept that both modalities can and should contribute. Sadly, I fear we are a long way from that happening.
 
Colleen: Another point you bring up is the problem of so-called “crowdsourcing” of medical information, which is then put into use in the clinical environment. Can you tell us what it is, how it has developed, and its current role (good or bad) in medical education?
Dr. Prabhu: Crowdsourcing is a word that, in this context, refers to the practice of asking a group of people to opine on a topic. It can also be used for fundraising and other endeavors. Crowdsourcing is interesting because it is a rapid way to accumulate data, financial support, signatures for petitions, or other endeavors that require large numbers of participants. As far as the role of crowdsourcing for medical education or clinical practice, I think it is important to note that there is no way to fully elucidate the source of information gathered in social media forums. Contributors may have competing interests, lack of experience, or other factors that limit the applicability of their opinions. It would be a real challenge to establish the specific conflicts and experience levels of the contributors at baseline, and on top of that, we are often discussing challenging clinical scenarios for which there are not high-level evidence publications. Still, data often follow the initial concepts introduced in social media forums, and a truly savvy doctor or surgeon should be taking all of this into account. For instance, when the Coronavirus pandemic came to the United States, multiple online groups rapidly mobilized to help each other treat the sickest patients when other information was not available. These groups conjectured about hydroxychloroquine, remdesivir, and antibody-rich plasma from previously affected patients. This was understandable given the desperation and uncertainty of the situation. Still, over time as data is accrued, we have an obligation to investigate the roles of the various medications and treatments that were touted on social media through peer-reviewed literature. I have also discussed cancer in the same context previously. Most of us probably wouldn’t want treatment that was only vetted from a Facebook group’s opinion, particularly if peer-reviewed literature on the topic were available. That’s not a slight against the social media contributors; it’s just the reality. That doesn’t mean that crowdsourcing doesn’t contribute to our greater knowledge, either. It just means that we all need to be able to understand the various content that is available, and to consider it in its proper context with relation to other content.
 
Colleen: With fundamental flaws in our current peer review system and flaws in deriving medical direction from social media, what is the practicing general surgeon to do in order to best serve the patient?
Dr. Prabhu: In my opinion, we all need to use our critical thinking skills a bit more, rather than trying to force information to meet our biases and discarding it when it doesn’t. We have to appreciate that technology should be praised and critically appraised in equal measure, and a critical appraisal doesn’t mean that a surgeon is against or attacking a certain technology. Surgeons should be able to look at social media forums and take away what is meaningful. That doesn’t mean that we are off the hook for reading contemporary literature, though. We all should be reading and thinking objectively about the information we are getting from articles. It is up to each surgeon to be responsible for sifting through the information and applying it to his or her specific practice scenario. Our current culture assumes that each surgeon with a platform or public visibility is either right or wrong, either loves or hates something, or supports social media or peer review but not both. We can see that manifested currently in many other ways, including politics and public health. In surgery, we are fortunate to be afforded a certain amount of autonomy in our practices. What we do with the information available is entirely up to us.

Dr. Prabhu’s articles can be accessed here (General Surgery News) and here (Surgical Innovation).

Resource Center

IBC Hot Topics in Surgery Webinar: Diversity and Burnout in Surgery—Watch here:
https://www.youtube.com/watch?v=LPtknt2DlQo

The New England Journal of Medicine Editorial Audio Interview: Guidelines for Covid-19 Vaccine Deployment
https://www.nejm.org/doi/full/10.1056/NEJMe2029435?query=featured_home

American College of Surgeons Bulletin Brief—September 15 Issue:
https://www.facs.org/publications/bulletin-brief/091520

Annals of Surgery Article: Patterns of NIH Grant Funding to Surgical Research and Scholarly Productivity in the United States
https://journals.lww.com

IBC Hot Topics in Surgery Webinar: The Nemesis for the General/Bariatric Surgeon: The Difficult Gallbladder in Severely Obese Patient—Watch here:
https://www.youtube.com/watch?v=oW_tNz6uTvA

Suggested Reading

Bariatric

Article: Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies. Selim Gebran, Brooks Knighton, Ledibabari Ngaage, John Rose, Michael Grant, Fan Liang, Arthur Nam, Stephen Kavic, Mark Kligman, Yvonne Rasko. Obesity Surgery (2020) 30:707–713.
https://pubmed.ncbi.nlm.nih.gov/31749107/
Dr. Eric DeMaria: This is an interesting survey of major health insurers regarding their policies for bariatric surgery.

Hernia

Article: Laparoscopic inguinal hernia repair in women: Trends, disparities, and postoperative outcomes. Am J Surg. 2019 Oct;218(4):726-729. Nicole Ilonzo, Jeanie Gribben, Sean Neifert, Erica Pettke, Michael Leitman.
https://pubmed.ncbi.nlm.nih.gov/31353033/
Dr. Ajita Prabhu: This article is interesting because it's starting to scratch at the surface of disparities in hernia care. While disparities in healthcare are a relatively hot topic across our country, relatively little literature exists to elucidate these issues. This article was written using a large database (NSQIP) as the data source and is somewhat limited by the inherent limitations of large data. However, it highlights that despite a known and established clinical advantage to performing laparoscopic inguinal hernia repair in women, that doesn't seem to be happening commonly in practice in the US. More work is needed in this area to improve this problem, which is likely multifactorial; however, identifying the issue is a good start.

Introduction

First and foremost, we would like to take this opportunity to extend our deepest condolences to the families, friends, and colleagues of Dr. Morris Franklin and Dr. Harvey Sugerman. Both icons in this field, they have contributed immeasurably to the field of surgery on not just a clinical level, but as mentors and leaders outside of the OR. Both men were an important part of MISS since its inception, and we will miss them greatly. Please look for a special tribute issue in your inbox shortly that will pay tribute to these great men.

This month’s issue features an interview with several members of our MISS faculty, including Leena Khaitan, Bradley Davis, Phil Schauer, Robin Blackstone, and John Dixon. These thought leaders devoted their time to discuss the role of artificial intelligence (AI) within healthcare and their particular areas of minimally invasive surgery.

I hope you also enjoy this month’s article recommendations from thought leaders in surgery, brought to you by leaders in surgical research and innovation. Thank you to these doctors for sharing their thoughts and opinions with us, and also to all of this month’s contributors!

–Colleen Hutchinson

How would you characterize the current and/or future role of AI within your surgical specialty? What do you have concerns about in this regard, if any?

Bradley Davis: We have embarked on the 4^th  industrial revolution and are experiencing a digital transformation in a variety of industries that impact the lives of providers and patients alike. With most of the information that we capture in the OR being digital, the next step is to develop platforms that can process these enormous amounts of data and create something meaningful that surgeons can use to assist in decision making. This is where machine learning and both predictive and prescriptive analytics will likely revolutionize the way we plan for and conduct surgical procedures. This technology is still maturing and will take several more years to see meaningful changes, but it will come and it will be impactful.

To some extent we are victims of our successes – the tools and equipment that we now have in our operating rooms are so effective that iterating around the next best thing has become a difficult value proposition. Cost is going to always be a consideration as it pertains to what incremental improvement we will realize in outcomes. This has been the biggest barrier in my opinion and has held us back in terms of these kinds of technology investments. Ultimately who is going to pay for it and what will be the ROI?

Robin Blackstone: The use of artificial intelligence in augmenting surgical therapy is coming to surgical treatment whether we engage in its development or resist it. Adoption of new technologies will be necessary to cope with the avalanche of information, research and patient-specific data that will inform surgical therapy in the future. One of the most promising is the use of artificial intelligence, potentially allowing surgeons to move beyond traditional search engines to integration of information from multiple sources, including big data, peer-reviewed research, and direct patient input.

Increasingly, surgical therapy is one choice among a group of medical options that include less invasive options, or part of a strategy that involves multimodality care. Determining the precise course of care optimal to a given individual will require integration of multiple data streams and logical choices, ideally offering decisions that are unbiased by personal experience in individual cases.

Surgery has a unique component of physical interaction with human tissues to achieve specific goals. Increasingly, the changes in anatomy are being understood in the context of the effect they achieve on physiology (metabolic surgery), an effect only now being understood and quantified. This casts outcomes into a different light – not only to realize a short-term objective but to avoid downstream negative consequences (eg, hypoglycemia).  Technology development and implementation is accelerating. There are significant challenges like interoperability of the data streams, privacy, and cost. There is a fear that use of AI integration will increase the distance between engagement with patients; ideally, though, if we can concentrate on feedback that is integrated into our course of care, it should free up our time and attention to engage in a more impactful way with our patients and ease working relationships between surgeons, colleagues, and teams.

Phil Schauer: AI is in its infancy regarding surgical specialties, so it’s hard to say right now its true benefit. But, especially in the area of decision support, I think it’s very promising. Smart phone apps are appearing that I believe are early forms of AI and aid surgeons in vital pre- and post-decision making based on strong data—for example, which operation to choose for bariatric surgery based on patient characteristics like BMI, age, diabetes, GERD, etc. Such AI can lead us a step closer to personalized medicine. My main concern with such AI support is the validation of accuracy. If such decision support tools are not based on sound, high level evidence, it’s the same old garbage in/garbage out conundrum that could potentially hurt patients.

John Dixon: AI has and will continue to impact all areas of healthcare. It’s here and will not go away – so let’s embrace it and learn about how we can use it and manage it. It’s early days, so all results are exploratory. AI will provide the opportunity to simplify the complex—or what may previously have been considered impossible.

All aspects of patient care will be impacted. In a bariatric-metabolic surgery practice, patient assessment will be streamlined to provide a higher level of complication detection and risk profile. A personalized approach to risk versus benefit will assist in a patient choosing to have an intervention, and guide which intervention. Enhancing the patient experience through personalizing, simplifying, educating, and selecting an appropriate clinical pathway will be possible. In addition, it will be based on the best available evidence. The assessment-to-treatment phase of care should be logical, timely, and without inappropriate barriers.

AI in biomedical research and engineering will accelerate discovery and the development of pharmacotherapy, devices, and performing surgery itself. Advances in robotics will change the complexity and nature of surgery that can be performed. Of course there will be winners and losers; there will be disruption; and any change is threatening.

Do you have a choice? No. Engage the future, and be a winner for yourself and your patients.

Leena Khaitan: I practice mostly foregut and bariatric surgery. Currently AI is not a part of the specialty, but I can see AI playing a role in the future. AI cannot replace surgeons in my opinion as human anatomy still has significant variation. However, there is great potential to make what we do better. For example, in laparoscopic cholecystectomy, AI technology can help identify/confirm the anatomy and ensure the “critical view” has been obtained. In the world of foregut surgery, we still have a lot of variability in the way antireflux procedures and hiatal hernias are performed. AI may help us to make this more standardized across surgeons to maybe improve the outcomes for everyone. AI technology may help with imaging to identify abnormalities using 3D reconstruction of the hiatal region and planning the surgery better. In bariatric surgery, there is great variability in sleeve construction. Using AI, we may better be able to identify the best way to make a sleeve for the best outcomes regarding weight loss and GERD, and may be a more effective approach than a multicenter trial to examine every step of the surgery.

Regarding concerns about AI…have you seen the movie Terminator and the way the machines took over the world?! But seriously, any technology can be used the wrong way. Medicolegally, there can be many issues surrounding AI as although the technology can provide insight, AI is still run by a computer and humans are unique. AI may miss things and vice versa. Also, any new technology is expensive. I think it will be many years until AI is mainstream in surgery.

Suggested Reading

Artificial Intelligence

Article: Artificial Intelligence in Surgery: Promises and Perils. Hasimoto DA, Rosman G, Rus D, Meireles OR. Ann Surg. 2018 Jul: 268(1):70-76.
https://pubmed.ncbi.nlm.nih.gov/29389679/

Robin Blackstone: Please see interview response above for feedback and insights on this article topic.

Article: The practical implementation of artificial intelligence technologies in medicine. He J, Baxter SL, Xu J, Hu Ji, Zhou X, Zhang K. Nat Med 2019 Jan 25(1):30-36.
https://pubmed.ncbi.nlm.nih.gov/30617336/

Robin Blackstone: Please see interview response above for feedback and insights on this article topic.

Bariatric

Article: Unintended consequences for patients denied bariatric surgery: a 12-year follow-up. Tsuda S, Barrios L, Schneider B, Jones DB. Factors affecting rejection of bariatric patients from an academic weight loss program. Surg Obes Relat Dis 2009 5(2):199-202.
https://pubmed.ncbi.nlm.nih.gov/32773144/

Dr. Dan Jones: Approximately one third of screened patients were not accepted for surgery by an academic bariatric program. Self- or social referral appeared to correlate with rejection because the BMI did not meet the criteria for surgery. This suggests inadequate information among social referral networks and/or in the media. Long-term follow-up will determine the health outcomes of patients not cleared for weight loss surgery.

Introduction

Don’t miss any of the past few weeks’ successful Virtual MISS 2020 panels and presentations. You can continue to obtain MISS CME right from your home because all meeting content has been archived and recorded and is available for viewing at your convenience. Check out the courses, presentations, and recorded live events here.

Additionally, we are back in your inbox this week with a new MISS E-News Surgeon Resource to keep you current. Last issue we gave you key insights from Dr. Delia Cortés Guiral, surgical oncologist, Colorectal Surgeon at King Khalid Hospital in Saudi Arabia. We discussed her recent article published in Colorectal Disease on validated occupational health safety measures to protect healthcare workers from accidental exposure to toxic aerosols in PIPAC procedures that could be implemented during laparoscopic surgery in COVID-19 patients. She also discussed how COVID-19 has affected her specialty and how she has adapted, and the COVID scene in both global locations where she operates—Madrid and Saudi Arabia.

This issue we speak with Dr. Mary Hawn, Chair of the Department of Surgery at Stanford University, about the paper she published recently on an algorithm she and her colleagues devised that has lead to better protection of OR team members during the pandemic and better conservation of personal protective equipment. Her JACS article can be read in full here. We also discuss what has been most challenging for her during COVID19, what may be challenging for other programs to implement regarding her published algorithm, and what permanent improvements may come out of the changes that the pandemic has necessitated from an OR standpoint. A special thanks to Dr. Hawn for devoting the time to conduct this interview!

We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center.

**Don’t forget to link to the Virtual MISS 2020 Symposium here.**

Stay safe and thank you for reading!

–Colleen Hutchinson

Interview with Dr. Mary Hawn

Colleen: Can you share with us the main takeaways or key pearls from your recent popular JACS publication, Precautions for Operating Room Team Members During the COVID-19 Pandemic?
[Background: The novel coronavirus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE).]
Dr. Hawn: The main takeaways from this publication are that all team members need to understand the risk of potential exposure throughout a surgical procedure. Intubation/extubation has the ability to generate aerosols, so only the minimally necessary team members should be in the OR room with appropriate PPE—likewise for surgical procedures that have the risk of generating aerosols of the aerodigestive tract such as endoscopy. Preoperative testing should be done whenever feasible to de- escalate PPE use.

Colleen: Do you foresee challenges in implementing components of the Stanford algorithm elsewhere?
Dr. Hawn: The main challenge is to get the COVID-19 result back prior to going to the OR for emergency cases and getting a workflow for COVID-19 testing that is efficient for a busy elective schedule.

Colleen: What has been the most challenging thing for you personally in your surgeon role during the COVID pandemic?
Dr. Hawn: The most challenging issues are ensuring that everyone understands different risk levels for transmission and how to protect themselves and others while conserving PPE. Our colleagues all have different risk tolerance and concerns, with some being too complacent and some being overly cautious. Striking that balance of reassuring everyone of the safety of proceeding with elective surgery and not fostering complacency is tricky.

Colleen: Do you think that coming out of this pandemic, there will be permanent improvements in certain processes, protocols, and patient care?
Dr. Hawn: I think that the pandemic has improved communication across the OR team regarding caring for each other and minimizing exposure to potentially harmful secretions. I believe it will improve the safety of the OR environment.

Dr. Hawn’s JACS article can be read in full here.

MISS E-News COVID Resource Center: Link to these!

Surgical Endoscopy article: The role of surgeons during the COVID-19 pandemic: impact on training and lessons learned from a surgical resident’s perspective
https://link.springer.com/article/10.1007/s00464-020-07790-3

IBC Hot Topics in Surgery Webinar: Covid-19, Thrombosis & Bariatric Surgery Webinar—Watch here:
https://www.youtube.com/watch?v=gq2pC0VArgc

The New England Journal of Medicine article: Multisystem Inflammatory Syndrome in U.S. Children and Adolescents
https://www.nejm.org/doi/full/10.1056/NEJMoa2021680?query=featured_home

American College of Surgeons: Assistance and Well-Being: The ACS offers this as a free resource to Fellows, Associate Fellows, and resident surgeons in the United States and Canada. Consider using the ACS Surgeon Well-Being Index to assess and track your overall well-being and identify areas of risk compared to physicians and residents across the nation.
Available here:
https://www.facs.org/member-services/surgeon-wellbeing

The New England Journal of Medicine Article: Genomewide Association Study of Severe Covid-19 with Respiratory Failure:
https://www.nejm.org/doi/full/10.1056/NEJMoa2020283?query=featured_coronavirus

IBC Hot Topics in Surgery Webinar: The Psycho-Sexual impact of Bariatric & Metabolic Surgery - Uncovering the Truths—Watch here:
https://www.youtube.com/watch?v=kEBFjTsgzZU

AIS Channel: 5 Things You Should Know About Watch & Wait Strategy for Rectal Cancer
https://aischannel.com/society/5-things-you-should-know-about-watchwait-strategy-for-rectal-cancer/

Suggested Reading

Bariatric

Article: Comparing the 5-Year Diabetes Outcomes of Sleeve Gastrectomy and Gastric Bypass: The National Patient-Centered Clinical Research Network (PCORNet) Bariatric Study. Kathleen M McTigue, Robert Wellman, Elizabeth Nauman, Jane Anau, R Yates Coley, Alberto Odor, Julie Tice, Karen J Coleman, Anita Courcoulas, Roy E Pardee, Sengwee Toh, Cheri D Janning, Neely Williams, Andrea Cook, Jessica L Sturtevant, Casie Horgan, David Arterburn, PCORnet Bariatric Study Collaborative. JAMA Surg 2020 Mar 4;e200087. Online ahead of print.
https://www.ncbi.nlm.nih.gov/pubmed/32129809

Dr. Luke Funk: Understanding differences in type 2 diabetes mellitus (T2DM) outcomes between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) is critical, given that patients with severe obesity and diabetes are commonly evaluated by bariatric surgery programs. Previously published randomized trials have not identified differences in T2DM outcomes between SG and RYGB, likely because they have not been powered for this outcome. This observational study followed over 10,000 SG and RYGB patients from 34 PCORnet institutions and found that more than 80% of patients experienced T2DM remission during the 5-year follow-up period. Yet, 33% and 42% of RYGB and SG patients, respectively, experienced T2DM relapse. Nearly half of the patients who underwent RYGB and one-third of patients who underwent SG had well- controlled hemoglobin A1c levels 5 years after surgery. These findings are relevant for bariatric surgeons because they summarize outcomes from a real-world setting (as opposed to a trial) and suggest that RYGB may be associated with better T2DM
outcomes compared to SG.

Introduction

Don’t miss any of the past few weeks’ successful Virtual MISS 2020! If you were unable to view sessions or live “Best of” panels, don’t worry. You can continue to obtain MISS CME right from your home because all content is archived and recorded for viewing at your convenience. Check out the latest live event of the last week, including Monday 6/22 and Wednesday 6/24’s Best Of Metabolic – Bariatric Surgery Parts I & II, and the recent Best of Foregut.

Additionally, we are back in your inbox this week with a new MISS COVID-19 Surgeon Resource to keep you current during this challenging time. Last week we gave you key insights from Dr. Mariana Berho, MD, Chair of Pathology and Laboratory Medicine at Cleveland Clinic Florida, and Dr. Gary Procop, Medical Director of Clinical Virology at the Cleveland Clinic, Ohio. This week we speak with Dr. Delia Cortés Guiral, surgical oncologist, European Certification on Peritoneal Surface Oncology, Consultant Peritoneal Surface Malignancies & Colorectal Surgeon, King Khalid Hospital, Saudi Arabia. We discuss her recent article published in Colorectal Disease on validated occupational health safety measures to protect healthcare workers from accidental exposure to toxic aerosols in PIPAC procedures that could be implemented during laparoscopic surgery in COVID-19 patients, how COVID-19 has affected her specialty and how have she has adapted, and the COVID scene in both global locations where she operates—Madrid and Saudi Arabia.

I’d like to thank Dr. Cortés Guiral for taking the time to speak with me for MISS E-News! We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center.

**Don’t forget to link to the Virtual MISS 2020 Symposium here!**

Stay safe and thank you for reading!

–Colleen Hutchinson

Interview with Delia Cortés Guiral

Colleen: According to the paper you just published in Colorectal Disease, PIPAC’s mechanism allows important parallels to be drawn in relation to laparoscopy in the COVID‐19 era. Can you elaborate?
Dr. Cortes-Guiral: Thanks for your question, Colleen. As soon as a concern emerged about the possibility of aerosol COVID-19 transmission during laparoscopic or robotic surgeries, we realized that there were some lessons about safety in the OR during minimally invasive surgery (MIS) that we had learned from the 10 years of experience with pressurized intraperitoneal aerosolized chemotherapy (PIPAC), which could be really useful. Specifically, the PIPAC system must be safely hermetically sealed to prevent escape of any of the intraperitoneal gas or fluid that contains chemotherapeutic agents. PIPAC is a laparoscopic procedure for delivering chemotherapeutic agents as an aerosol to treat advanced peritoneal metastases with a palliative or neoadjuvant intent.

In this article, we present the validated occupational health safety measures to protect healthcare workers from accidental exposure to toxic aerosols during PIPAC procedures that could be implemented during laparoscopic surgery in COVID-19 patients. These protective measures include the following: Controlling the abdominal distension by reducing the number of trocars to a minimum, by the use of balloon trocars, and by verifying zero gas flow on the panel of the CO 2 insufflator. Since some insufflators are able to reabsorb CO 2 in order to prevent intra-abdominal pressure peaks, a microparticle filter should be intercalated on the CO 2 inflow line between the insufflator and the patient. Desufflation of the toxic aerosols occurs over a closed aerosol waste system (hermetic tubing with two consecutive microparticle filters); this system is then connected to a mobile high-efficiency particulate air (HEPA) filter. As an additional safety measure, the patient is completely covered with a large plastic drape extending to the floor. The plastic drape is perforated, and a stoma bag is used to seal around the hermetic tube system connected to a mobile HEPA filter system.

Colleen: What are the main takeaways of the publication regarding COVID-19’s impact on colorectal surgery?
Dr. Cortes-Guiral: The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems, with the collapse in many institutions forced to cancel and postpone elective colorectal surgeries; however, the need for urgent and emergency colorectal surgery (symptomatic cancer as well as patients with perforated diverticulitis, toxic colitis, and other acute problems) in COVID-19 patients was a risk of exposure for OR staff. This publication aims to present several recommendations and alternatives according to the resources of the centers for a safe laparoscopic colorectal surgery or the recommendation for open surgery with adequate PPE in case laparoscopic surgery cannot be performed under the mentioned protective measures. These include all the validated security measures from PIPAC protocols to create a hermetic system to avoid escapes of gas, other alternatives such as use of an active smoke evacuator connected to a proper filter, the addition of a system of intra-abdominal electrostatic precipitation—which is able to sediment the aerosolized virus to the peritoneum, and the importance of negative pressure ORs (in the corner of the surgical area preferably).

Colleen: How has COVID-19 affected your specialty and how have you adapted?
Dr. Cortes-Guiral: As a surgical oncologist, I have lived two different scenarios in Spain (Madrid) and in Saudi Arabia. In Madrid, the surge was so severe that there was a real shortage of ICU beds. Consequently, all major elective oncologic surgeries requiring (or potentially requiring) an ICU bed had to be postponed. Best strategies to deal with that situation were to propose the patients receive extended neoadjuvant therapy or to be relocated to COVID-free hospitals when possible. In Saudi Arabia, early containment and physical distancing measures as well as implementation of healthcare capability allowed us to keep on operating on all oncologic patients during the peak of the surge in the country. Surgical oncologists and colorectal surgeons around the world have experienced the impact of the pandemic on the care of cancer patients with important delays or alteration in the timing for diagnosis, treatment, and follow-up. The main surgical societies are demanding authorities define strategies to guarantee treatment of cancer patients during plausible future surges.

Colleen: What are the current policies in the two countries where you practice for COVID-19 protocols, such as testing of patients and staff prior to surgery or other in-hospital treatment?
Dr. Cortes-Guiral: Currently in Madrid, staff is tested if they have any symptoms or have suffered any potential risky exposure; for patients, every patient admitted to the hospital or undergoing emergent or elective surgery is tested (at least 48 hours before admission in the case of elective surgery). Clinical and epidemiological tests are required as well. In Saudi Arabia, some centers are testing all patients before admission but other centers only test patients with a positive clinical test, according to the availability of quick tests.

Colleen: What are the main takeaways of the publication regarding COVID-19’s impact on colorectal surgery?
Dr. Cortes-Guiral: The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems, with the collapse in many institutions forced to cancel and postpone elective colorectal surgeries; however, the need for urgent and emergency colorectal surgery (symptomatic cancer as well as patients with perforated diverticulitis, toxic colitis, and other acute problems) in COVID-19 patients was a risk of exposure for OR staff. This publication aims to present several recommendations and alternatives according to the resources of the centers for a safe laparoscopic colorectal surgery or the recommendation for open surgery with adequate PPE in case laparoscopic surgery cannot be performed under the mentioned protective measures. These include all the validated security measures from PIPAC protocols to create a hermetic system to avoid escapes of gas, other alternatives such as use of an active smoke evacuator connected to a proper filter, the addition of a system of intra-abdominal electrostatic precipitation—which is able to sediment the aerosolized virus to the peritoneum, and the importance of negative pressure ORs (in the corner of the surgical area preferably).

Colleen: How has COVID-19 affected your specialty and how have you adapted?
Dr. Cortes-Guiral: As a surgical oncologist, I have lived two different scenarios in Spain (Madrid) and in Saudi Arabia. In Madrid, the surge was so severe that there was a real shortage of ICU beds. Consequently, all major elective oncologic surgeries requiring (or potentially requiring) an ICU bed had to be postponed. Best strategies to deal with that situation were to propose the patients receive extended neoadjuvant therapy or to be relocated to COVID-free hospitals when possible. In Saudi Arabia, early containment and physical distancing measures as well as implementation of healthcare capability allowed us to keep on operating on all oncologic patients during the peak of the surge in the country. Surgical oncologists and colorectal surgeons around the world have experienced the impact of the pandemic on the care of cancer patients with important delays or alteration in the timing for diagnosis, treatment, and follow-up. The main surgical societies are demanding authorities define strategies to guarantee treatment of cancer patients during plausible future surges.

Colleen: What are the current policies in the two countries where you practice for COVID-19 protocols, such as testing of patients and staff prior to surgery or other in-hospital treatment?
Dr. Cortes-Guiral: Currently in Madrid, staff is tested if they have any symptoms or have suffered any potential risky exposure; for patients, every patient admitted to the hospital or undergoing emergent or elective surgery is tested (at least 48 hours before admission in the case of elective surgery). Clinical and epidemiological tests are required as well. In Saudi Arabia, some centers are testing all patients before admission but other centers only test patients with a positive clinical test, according to the availability of quick tests.

MISS E-News COVID Resource Center: Link to these!

AIS Channel: Care for the Cancer Patient with Heidi Nelson
https://covid19.aischannel.com/leadership2b/videos/care-for-the-cancer-patient-heidi-nelson

AIS Channel: The impact on surgical journals with Susan Galandiuk
https://covid19.aischannel.com/leadership2b/videos/the-impact-on-surgical-journals-susan-galandiuk

Surgical Endoscopy article: COVID-19 and impact on peer review
https://www.springer.com/journal/464/updates/17818222

American College of Surgeons Bulletin: ACS COVID-19 Update
https://www.facs.org/covid-19/newsletter/050820

American College of Surgeons: Surgeon Voices in the COVID-19 Era Nancy Gantt, MD, FACS, sends a message to colleagues in the health care community encouraging well-being and use of the ACS COVID-19 Registry.
https://www.facs.org/covid-19/newsletter/050820/frontlines

ASMBS position statement entitled, "Safer Through Surgery," published online in the journal SOARD:
https://www.soard.org/article/S1550-7289(20)30318-X/fulltext

IBC COVID-19 Webinar: Redefining New Standards in Metabolic Medicine & Surgical Research—Watch here:
https://www.youtube.com/watch?v=Ld7H-GqGaNQ&feature=emb_title

Suggested Reading

Bariatric

Article: Bariatric peri-operative outcomes are affected by annual procedure-specific surgeon volume. Altieri, M.S., Pryor, A.D., Yang, J. et al.  Surg Endosc (2019). https://www.ncbi.nlm.nih.gov/pubmed/31388803

Dr. Jessica Ardila-Gatas & Dr. Aurora Pryor: This article highlights how the peri-operative outcomes of bariatric surgery are affected by the annual surgeons’ operative volume. It shows the importance of procedure-specific volume to predict outcomes, including length of stay, overall morbidity, and readmission rate, for both Roux-en-Y gastric bypass and sleeve gastrectomy. This article shows thatthe surgical skills for one procedure did not predict outcomes for the other bariatric procedure. Limitations are that this is an administrative database, it may not capture all patients, and it doesn’t include the effect of weight on the peri-operative risk. However, the importance of annual volume in maintaining skills translating into good outcomes can be appreciated.

Introduction

Don’t miss Virtual MISS 2020! It’s going on now—but if you missed sessions or live “Best of” panels, don’t worry—all live content is archived for viewing at your convenience. Get your CME right from your home—with superior content that requires no travel. If you want to view the live events of the last week, including Tuesday 6/9 Best of Colon and Thursday 6/11 is Best of Hernia, or the most recent Best of Enhanced Recovery after Surgery, click here!

Additionally, we are back in your inbox this week with a new MISS COVID-19 Surgeon Resource to keep you current during this challenging time. Last week we gave you key insights from Dr. Francesco Rubino, world-renowned surgical expert on the pathophysiology of diabetes and obesity, on 2020 MISS and the power of a quality meeting in-person and online, current COVID publications and peer review, the recent surgeon recommendations from the Diabetes Surgery Summit COVID-19 webinar, and COVID’s impact on several facets of healthcare in the United Kingdom.

This week I speak with Dr. Mariana Berho, MD, Chair of Pathology and Laboratory Medicine at Cleveland Clinic Florida, and Dr. Gary Procop, Medical Director of Clinical Virology at the Cleveland Clinic, Ohio. Dr. Procop oversees molecular diagnostic testing and has evaluated numerous molecular platforms for COVID testing and we discuss various aspects of testing with both doctors.

I’d like to thank Drs. Procop and Berho for taking the time to speak with me for MISS E-News! We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center.

**Don’t forget to link to the Virtual MISS 2020 Symposium here!**

Stay safe and check back next week for more!—Colleen Hutchinson

–Colleen Hutchinson

Interview with Dr. Gary Procop & Dr. Mariana Berho

Colleen: How would you characterize the reliability of testing of COVID-19 currently—diagnostic molecular and diagnostic antigen, and antibody tests?
Dr. Procop and Dr. Berho: The molecular diagnostic assays may be characterized as highly to moderately sensitive. All but one of these assays hold the FDA Emergency Use Authorization only for symptomatic patients, although it is clear that many providers are using these for screening in asymptomatic patients. The pre-test likelihood (ie. symptomatic versus asymptomatic patients) has a direct influence on the reliability of the test result. It is important that these nuances are understood by the end users.

The COVID antigen detection test will likely have sensitivities similar to other antigen detection tests, which will be similar to a moderately sensitive molecular test. Both of these assays will need followup with a highly sensitive molecular assay, if the provider suspects COVID-19.

The use of the antibody test is highly controversial and has been commercialized in a manner that has outpaced scientific knowledge. There are recognized issues with false positive reactions. It is important that the presence of antibody is not assumed to represent immunity. The presence of antibody has never been demonstrated to correlate with immunity. Clarifying studies are ongoing.

Colleen: How has COVID-19 affected your specialty and how have you adapted?
Dr. Procop and Dr. Berho: Many pathologists have become SARS virus experts! Members of the laboratory have needed to adapt to the insourcing of rapid and routine diagnostic testing for SARS-CoV-2. We have had to struggle with limited allocation, as well as the limited-to-non availability for reagents, instruments, swabs, and transport media. Theneed to quickly adapt to these challenges in conjunction with our clinical colleagues has necessitated clear communication and many, many meetings.

Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery or other in-hospital treatment?
Dr. Procop and Dr. Berho: This is a challenging question and we are learning as we go. We are currently testing all pre-surgical patients. The positivity rate in these asymptomatic patients in this setting is extremely low (about 1/200 or 0.5%). Additionally, many of these represent low-level viral fragment shedding of remote disease, which is not considered infectious. Therefore, as we learn more and prevalence rates change, I could foresee these practices being modified.

Colleen: Do you think that all staff at a medical institution should be tested for COVID-19?
Dr. Procop and Dr. Berho: No. Medical professionals should be on an honor system and not come to work sick. Temperature monitoring, social distancing when possible, and the consistent wearing of masks has served our institution as appropriate. The testing of asymptomatic caregivers would cause the same issues as described above for asymptomatic pre-surgical patients.

MISS E-News COVID Resource Center: Link to these!

Annals of Surgery Brief Clinical Report (Online only): Abdominal Surgery in Patients with COVID-19: Detection of SARS-CoV-2 in Abdominal and Adipose Tissues
https://journals.lww.com

Surgical Endoscopy article: Detect to protect: pneumoperitoneum gas samples for SARS-CoV-2 and biohazard testing
https://link.springer.com/article/10.1007/s00464-020-07611-7

American College of Surgeons Joins New Surgical Care Coalition:
https://www.surgicalcare.org

ASMBS Webinar:  Keeping Your Patients Engaged During the COVID-19 Crisis & Care for the Caregivers to Avoid Professional Burnout
https://asmbs.org

OR Management News Article: Key Steps to Regain OR Capacity After COVID-19
https://www.ormanagement.net

SAGES Guidelines: Safe Cholecystectomy Multi-Society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury during Cholecystectomy
https://www.sages.org

IBC COVID-19 Webinar: How Extended Reality (XR) Can Have a Positive Impact on Surgical Education During the COVID-19 Pandemic—Watch here:
https://www.ibcclub.org/hot-topics-june-2

Suggested Readings

Bariatric

Article: Micronutrient Intake and Biochemistry in Adolescents Adherent or Nonadherent to Supplements 5 Years After Roux-en-Y Gastric Bypass Surgery.
Henfridsson P, Laurenius A, Wallengren O, et al. Surg Obes Relat Dis. 2019 Sep;15(9):1494-1502.
https://www.ncbi.nlm.nih.gov/pubmed/31371184

Dr. Dimitrios Pournaras: The number of children and adolescents affected by obesity continues to grow and, as seen in adult populations, lifestyle interventions have been met with limited success. Bariatric surgery in this age group remains a controversial issue; however, there is a growing body of evidence to support it as a treatment for adolescents suffering from severe obesity. Nutrient supplementation following Roux-en-Y gastric bypass in the adult and adolescent population is essential; however, not only are nutritional needs higher in adolescents, but they also present unique challenges with regard to adherence. This study demonstrated that about half of adolescents were adherent with supplementation, supporting recommendations for ongoing monitoring of micronutrient intake and biochemistry postoperatively.

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