Introduction

This month’s issue features an interview with Dr. Julie Thacker. Dr. Thacker devoted her time to discuss some issues surrounding enhanced recovery, including its evolution, adoption, and lessons learned from implementation on colorectal surgery, and which enhanced recovery intervention has greatest benefit, has greatest effect on cost reduction, is least effective, and is most promising but needs more data. 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, especially our newest—Timothy E. Miller, MB, ChB, Chief, Division of General, Vascular, and Transplant Anesthesiology and Clinical Director, Abdominal Transplant Anesthesiology, Duke University School of Medicine. Please stay safe and healthy!

–Colleen Hutchinson

Colleen: How would you characterize the evolution of utilization of enhanced recovery in minimally invasive surgery (MIS)?
The adoption of enhanced recovery in the US has been exciting to watch; in summary, though, this adoption has been exactly like every other change management program in healthcare. Early adopters in the private space at smaller hospitals have been able to successfully create programs in short order. This was followed by academics writing up small series of essential case reports and series and detailing success. Some have written and presented their experience, usually limited to a subspecialty, and surgical societies have highlighted these. There has also been funding of individual, health system and, more broadly, national implementation programs. Each of these has some version of compromise and a good dose of directed, protocol-driven standards. Most of these are based on evidence of overall impact or adoption of a change management program that saved days in hospital or money.
 
What has not happened is widespread adoption of the principles of enhanced recovery for the betterment of all surgical patients in the US. There is still significant resistance to the application of certain proven elements, such as defined fluid management and preoperative optimization. Any element that seems to have an up-front cost or is identified as difficult has been disproportionately scrutinized. For example, the use of a maltodextrin-rich preoperative carbohydrate drink has science behind it. But because in the US this piece has been costly to healthcare systems or awkward to get to patients, it is commonly converted to accessible and perhaps harmful high carb juice or nothing—back to "NPO." Another important example currently is the knowledge that optimizing patients preoperatively is very clear and well supported; however, we will only take this on in the US if there is no risk to our operative schedule and volume. This means if you tell a US surgeon to delay an operation in order to optimize a patient's nutrition for best outcomes (and risk not filling an OR schedule or losing a patient to someone who won't delay the intervention), this is unlikely to be heeded. In general, elements are adopted in the private sector when they show immediate benefit and cost savings. In the academic setting, adoption is very influenced by dogma. The systems with adoption driven by administration are, of course, cost-focused.

Colleen: Given the opioid crisis, as well as pressure to reduce costs and improve patient satisfaction, what needs to be done within MIS to further its utilization?
There is great opportunity for MIS operations in combination with enhanced recovery. The greatest struggle here is two-pronged. One difficulty is with our anesthesia colleagues; the other is US patient expectations. Our anesthesia colleagues cannot estimate surgical stress from a case name. They have shared our excitement about “faster” recoveries following MIS approaches to operation. Lap chole? Okay, the decreased incision is absolutely indicative of less surgical stress. But there are many lap or robotic operations where the greatest benefit of enhanced recovery is related to decreasing the complication risk, not a decreased need for multimodal pain management or attention to perioperative fluid. It is difficult for the anesthesia team to appreciate the need for multimodal analgesia and fluid management when they only see little tiny incisions and less impressive fluid shifts, especially when their care period ends 1 to 2 hours after extubation.
 
Secondly, widespread avoidance of any perioperative opioids would be extremely impactful to the opioid crisis. This has, as of yet, been impossible without full system buy-in, from time of surgical diagnosis through recovery. US patients have an expectation of “pain-free” surgery. It takes time and patience to address this case after case and phone call after phone call. Surgeons cannot be alone in this effort, because when we are, we fail. When we are the only ones prompting opioid-free/sparing perioperative pain management, the patient receives narcotics for block placement, for the ride to the OR, for induction, and in the PACU, not to mention on the ward. When we solely carry this message postoperatively, the emergency doctor, primary care physician, or oncologist provides the narcotic we tried so hard to avoid. Our system needs to foster the goal of minimal narcotics as a patient satisfaction tool, and incentives to patients and providers alike could contribute to this.
 

Colleen: What are the lessons learned from its initial implementation in colorectal surgery?
Not all bad outcomes are because of its lower gut risks. Yes, ileus is still an issue, but less so. Yes, SSI is still important to work on, but this has been cut in half for most enhanced recovery programs. The greatest lessons learned in colorectal enhanced recovery all stem from blowing up dogma. We have faced our fears of PONV, anastomotic leak, and SSI. We’ve denied risks based on science when we can, and we’ve recognized when we don’t have science for areas of future focus. My experience learning, implementing, and teaching enhanced recovery has been to challenge myself and my colleagues to implement the evidence. We don’t have it all figured out, but we have been able to stop hurting patients with our beliefs, passed on from surgeon to surgeon.
 

Colleen: Which enhanced recovery intervention:
 
1- Has greatest patient benefit? Probably attention to fluid management. Not all the answers are in yet, but generally working towards a less harmful goal IVF in the OR and the early postoperative period has decreased some of the most serious complications we used to cause with fluid overload: atrial arrhythmia, bowel swelling threatening anastomosis and causing ileus just as examples.

2- Has greatest effect on cost reduction? Defined discharge criteria. While one day in the hospital is not that expensive, the complications that occur during each day in the hospital, as well as several days in the hospital, really add up to savings.

3- Is least effective, or harmful and should not be done? Fluid restriction without monitoring. Because the mean was excessive, fluid delivery advice was generally to “use less;” however, this in some situations was taken to an inappropriate extreme. It became a badge of honor to finish a case with minimal fluid, but we have now shown that there is likely a “healthiest middle ground,” for the elective operation. There is nothing better about giving too little fluid than there was about giving too much. This observation applies much more commonly to the intraoperative phase; however, concerning perioperative acute kidney injury (AKI) and postoperative complication management, the same can be said for postoperative management by the surgical team.

4- Is most promising but needs more data to evaluate before wide use? We need to quit electively operating on patients we know will have complications. The data necessary is more robust evidence regarding risk stratification, complication predictability, true informed consent, and system support to better evaluate and prepare patients. Doing the right thing costs surgeons and systems more time and money than just “getting by.” Redirecting our efforts to be patient-based, from everyone’s perspective, will be the ultimate success of enhanced recovery and perioperative medicine.

Suggested Readings

Hernia

Article: Revision of sleeve gastrectomy with hiatal repair with gastropexy for gastroesophageal reflux disease. Soong TC, Almalki OM, Lee WJ, Ser KH, Chen JC, Wu CC, Chen SC. Obes Surg. 2019 Aug;29(8):2381-2386. https://www.ncbi.nlm.nih.gov/pubmed/31001757
Dr. Rees Porta: What do you do with the patient with excellent weight loss after sleeve gastrectomy but now has a hiatal hernia and GERD who is passionately disinterested in conversion to RYGB or augmentation with LINX? Although only 28 patients were included, at least we now have some data to quote for those patients who chose to undergo cruroplasty and gastropexy alone. While safe, GERD-HRQL scores only dropped from 24.3 to 18.9 at one year, PPI was discontinued in 26%, and only 50% of patients were satisfied with the surgery. While I agree with the authors that this is a safe and technically feasible procedure, I personally feel like conversion to RYGB remains the gold standard (for now).

Foregut

Article: Restrictive versus Liberal Fluid Therapy For Major Abdominal Surgery. Myles PE, Et Al. N Engl J Med. 2018 Jun 14;378):2263-2274. https://www.ncbi.nlm.nih.gov/pubmed/29742967
Dr. Tim Miller: The Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery (RELIEF) study is the largest trial to date of perioperative fluid management. The 3000-patient trial comparing two different fluid regimes showed that a restrictive fluid regimen during and up to 24 hours after surgery was associated with an increase in acute kidney injury (AKI). This result is at odds with a recent trend to a more restrictive fluid approach during major surgery, and suggests that practice may have become too restrictive. A moderately liberal (aiming for 1-2 liters positive) or goal-directed approach is therefore recommended.

Endoscopy & General

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://www.ncbi.nlm.nih.gov/pubmed/29389679
Dr. Robin Blackstone: One technology that really makes physicians and surgeons nervous is Artificial Intelligence.  As physicians, we are inundated with vast volumes of new information to acquire, digest and use. AI is going to be one of those crucial tools that we will have to accept and integrate into practice.  Surgical resident, Dan Hashimoto, MD, the Innovation Fellow at Harvard, second generation surgeon and tech genius gives us a preview of what to expect in terms of value, challenges and how to harness the capabilities of AI to surgeon goals.

Colon

Article: Is there a relationship between tobacco smoking and recurring ileocolic Crohn’s disease? Bolckmans R, Kalman T, Singh S, Ratnatunga KC, Myrelid P, Travis S, George BD. Dis Colon Rectum. 2020 Feb;63(2):200-206. https://www.ncbi.nlm.nih.gov/pubmed/31842162
Dr. Steven Wexner: Links between Crohn’s disease and tobacco smoking have been intimated for the last several decades. The most recent publication by Bolckmans and coworkers evaluated 290 patients who underwent ileocolic resection for Crohn’s disease during a 12-year period. Unfortunately, tobacco smoking data were only available for 242 (83%) of the 290 patients, including 42 active smokers and 169 non-smokers at the time of resection. The authors were able to use Kaplan-Meier survival analysis to demonstrate a significantly higher rate of surgery being required for primary ileocolic Crohn’s disease in the 17% of tobacco smokers who continue to use tobacco until their last follow- up. Specifically, while only 3 of the 31 patients (10%) who ceased tobacco smoking following their first resection required a subsequent resection for recurrent ileocolic Crohn’s disease, 16 of the 42 patients (38%) who continued to smoke tobacco following their first resection required an additional resection.  One additional finding was that while only 14% of patients who ceased tobacco smoking following their first resection received immunomodulatory therapy following surgery, 46% of patients who continued tobacco smoking following the first resection received immunomodulatory maintenance therapy following the first resection. The authors concluded that smoking cessation was associated with a lower incidence of immunomodulatory maintenance therapy, as well as a lower incidence of redo ileocolic resection for current Crohn’s disease. I congratulate the authors on their interesting study and urge surgeons and gastroenterologists to counsel tobacco smoking patients undergoing ileocolic resection for Crohn’s disease regarding the benefits of tobacco smoking cessation.

Bariatric

Article: Metabolic Changes and Diabetes Microvascular Complications 5 Years After Obesity Surgery. Miras AD, Ravindra S, Humphreys A, Lascaratos G, Quartey KNK, Ahmed AR, Cousins J, Moorthy K, Purkayastha S, Hakky S, Tan T, Chahal HS, et al. Obes Surg. 2019 Dec;29(12):3907-3911. https://www.ncbi.nlm.nih.gov/pubmed/31372874
Dr. Dimitrios Pournaras: One of the primary indications for bariatric surgery is the treatment of poorly controlled type 2 diabetes in patients who suffer from obesity, with the overall aim of preventing the development or progression of secondary complications. Although it is well recognized that there are rapid improvements in glycemic control, comparison of remission rates across studies is complicated as many fail to use standardized criteria. This retrospective review sheds light on the effect of applying the International Diabetes Federation (IDF) criteria on five-year diabetes remission rates and its implications for the development of microvascular complications. Although the findings demonstrate the efficacy of bariatric surgery in improving renal function and stabilizing the progression of retinopathy, it also highlights the importance of using standardized criteria for remission. Applying the IDF parameters, remission rates were much lower than the authors expected. Recognition of relapse is critical in identifying patients who require more intensive treatment to prevent the development or progression of diabetes-related complications.

Introduction

This year the Minimally Invasive Surgery Symposium (MISS) is hitting a major milestone, as we prepare to celebrate its 20^th anniversary. I had the opportunity to speak to Philip Schauer, MD, Executive Director of the Minimally Invasive Surgery Symposium, and in this interview we cover a variety of topics, including what to expect at MISS 2020, new devices and techniques in minimally invasive surgery (MIS), and some more specific topics such as implementation of enhanced recovery after surgery, the number of sleeves being performed (is it too many?), and metabolic surgery for NASH.

I hope you also enjoy this month’s article recommendations from thought leaders in MIS, brought to you by leaders at the forefront of surgical research and innovation. Dr. Benjamin Poulose recommends two articles that draw attention to the current and growing burden of healthcare costs on the middle class, Dr. Manoel Galvao Neto draws our attention to the latest research findings on endoscopic duodenal mucosal resurfacing for the treatment of type 2 diabetes mellitus, and Dr. Luke Funk shares an article on the YOMEGA trial, highlighting the efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for obesity. In addition, there is a recommended colon surgery cohort study that looked at the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. Enjoy, and we hope to see you in Las Vegas next month at the 2020 20^th MISS!

–Colleen Hutchinson

Colleen: This is an exciting year to be attending MISS—its 20^th anniversary—congratulations! How would you characterize your feelings on this accomplishment and the meeting’s evolution over these two decades?
Dr. Schauer: I cannot believe it has been 20 years. I was young when MISS started and now—not so young! For our 20th anniversary, we will take multiple trips down memory lane and reflect on the incredible advances in MIS since our first symposium in 2001. To put the trajectory in perspective, many of our current attendees were not even in high school then and are now full-sledged surgeons, many of whom oversee their own programs and practices. We won’t dwell too much on our glorious past so that we can embrace the future of surgery and make predictions on the next 20 years. It is a very interesting time to do so. Then in another 20 years at MISS 2040, we’ll see just how close we came!

Colleen: What are some faculty presentations you are looking forward to?
Dr. Schauer: We have both surgeons and non-surgeons on our faculty who provide valuable knowledge and perspectives on a wide range of topics. Steve Nissen, MD, is a cardiologist at Cleveland Clinic and one of the most well-known and respected surgeons internationally. He will speak about obesity as the major driver of cardiovascular disease—the number one killer in America, and how metabolic surgery can potentially reduce heart attack, stroke, and death. Dr. Lee Kaplan is a gastroenterologist at Harvard and President of The Obesity Society. Lee will speak about how medications may reduce obesity comorbidities and how they can be used before and after metabolic surgery. Dr. John Dixon, Professor of Medicine at Monash University (Australia), leads our Metabolic Surgery Program and will address the critical issue of “Obesity Stigma and Prejudice,” which is a key factor in stalling progress in both obesity research and treatment.

Some surgeons whose presentations I am looking forward to are: Dr. Aurora Pryor, Professor of Surgery at Stonybrook and President of SAGES, is a top expert in foregut and metabolic surgery who will present on the controversial topic of surgical volume and outcome relationships. Dr. Tammy Kindel, Assistant Professor of Surgery at University of Wisconsin, will present on how metabolic surgery may improve the devastating effects of heart failure, a relatively new finding that may expand use of metabolic surgery. Our hernia and colon surgery programs are also excellent, with each incorporating best practices and new advances from the world's leading experts.

Colleen: Michel Gagner is back on the faculty of MISS this year! He is always a pleasure to work with and brings critical clinical and research experience to the faculty. Can you comment on this?
Dr. Schauer: Dr. Michel Gagner is one of the most experienced and innovative bariatric surgeons in our field, and he has contributed much to MISS over the years. I can remember in 2003 when he presented some of his initial work at MISS on sleeve gastrectomy as a bridge to duodenal switch. It was the first time this work had been presented publicly. Our group (located in Pittsburgh at that time) quickly began performing sleeve gastrectomy especially in the higher risk patients and published our findings in 2006. Now it is the most common bariatric procedure…and that’s just one of Michel’s many innovative ideas. We are so please to have Michel back again for our 20^th.

Colleen: Are you implementing new standards for enhanced recovery?
Dr. Schauer: Yes—this is a must for all of us in 2020. The real question is: Which modalities actually benefit the patient? This question, evidence surrounding its answer, and enhanced recovery modalities that all surgeons must implement today will be discussed at MISS 2020. The focus is under the guidance of Julie Thacker, Associate Professor of Surgery at Duke, who is leading our MISS Enhanced Recovery from Surgery Program. She and her colleagues will discuss enhanced recovery modalities that all surgeons must implement today. Come to MISS and find out from experts with evidence!

Colleen: What are some new techniques and technologies/devices in MIS that you find most promising (in trial or approved)?
Dr. Schauer: I like LinX for GERD, robotics for certain applications, fluorescent imaging, new endoscopic techniques for GERD and weight loss and diabetes, Transversus abdominis plane (TAP) block for postoperative pain reduction, and new approaches to abdominal wall reconstruction (AWR).

Colleen: Some say the next big thing is metabolic surgery for NASH. What’s your take on this?
Dr. Schauer: This is critical; NASH is deadly. Metabolic surgery is the only treatment that has consistently shown reversal of NASH, but we need level 1 evidence. In past symposiums, we presented a sound rationale for metabolic surgery to specifically treat NASH. The evidence is mounting that NASH may resolve or certainly improve, which is critical given that NASH is a deadly disease resulting in cirrhosis or severe cardiovascular disease in a majority of patients.

Colleen: What can general surgeons do to develop or improve procedure reimbursement strategies?
Dr. Schauer: It is all about documentation. Surgeons and hospitals leave earned money on the table because they do not document properly patients’ disease severity. A little more effort documenting is well worth it. We address both the challenges and proven processes to meet that documentation need at MISS.

Colleen: Are we performing too many sleeves?
Dr. Schauer: Sleeve gastrectomy is a very effective metabolic procedure, but not for every patient. As we move more toward personalized medicine, surgeons should consider many patient factors such as BMI > 50, gastroesophageal reflux disease (GERD), and diabetes that, based on evidence, may suggest better outcomes from other procedures like gastric bypass and duodenal switch. We will educate MISS attendees on available smart phone apps to help guide their decision-making for best patient outcomes.

Suggested Readings

Colon

Article: Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. A. Olsson, O. Kiwanuka, and O. Stackelberg. BJS Open 2019 Dec;3(6):750-758. https://www.ncbi.nlm.nih.gov/pubmed/31832581
Dr. Benjamin Poulose: I consider this a potential landmark article that has yet to be recognized. The authors present a well-designed prospective case series of 60 women who underwent management of post-partum diastasis recti. The management of this entity, commonly encountered by abdominal wall specialists, remains without well-collected data until now. Patients underwent a formalized physical therapy regimen targeting abdominal core musculature. Those who did not respond well proceeded to operative double plication of the linea alba. Patient-reported abdominal core ‘trunk’ function improved in 98% of patients. 76% of patients had improvement in exercise testing. Strikingly, nearly half of women reported improvement in urinary incontinence inventories after operation. This study supports the concept of abdominal core health – in which the anterior abdominal wall is related to the pelvic floor, which is in turn related to the back and diaphragm. Improvements in one area may modulate symptoms in another area. It is a novel concept and one that warrants further investigation, especially as it pertains to women’s health.

Bariatric

Article: Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for obesity (YOMEGA): a multicentre, randomised, open-label, non-inferiority trial. Robert M, Espalieu P, Pelascini E, et al. Lancet. 2019 Mar 30;393(10178):1299-1309. https://www.ncbi.nlm.nih.gov/pubmed/?term=30851879

Dr. Luke Funk: Single anastomosis bariatric procedures have increased significantly throughout the world over the past several years, but there are very few prospective, randomized trials comparing them to other operations, such as Roux-en-Y gastric bypass. The YOMEGA trial was a multicenter trial conducted at 9 centers in France. It randomized bariatric surgery patients to either one anastomosis gastric bypass (OAGB) (n=129) or Roux-en-Y gastric bypass (RYGB) (n=124). The primary outcome of the trial was % excess BMI loss at 2 years. Mean % excess BMI loss at 2 years was similar - 87.9% for OAGB patients and 85.8% for RYGB patients. However, there were twice as many serious adverse events in the OAGB group compared to the RYGB group. These included complications such as diarrhea and nutritional deficiencies. This study is relevant to bariatric surgeons because it is represents the highest quality evidence published to date comparing these two procedures.

General

Article: Burden of Health-Care Costs Move to the Middle Class. Sussman AL. Wall Street Journal 2016 Aug 25. https://www.wsj.com/articles/burden-of-health-care-costs-moves-to-the-middle-class-1472166246
Article: Employer-Provided Health Insurance Approaches $20,000 a Year. Mathews AW. Wall Street Journal 2018 Oct 3. https://www.wsj.com/articles/employer-provided-health-insurance-approaches-20-000-a-year-1538575201

Dr. Benjamin Poulose: These two articles should be mandatory reading for any provider or administrator in health care today. It highlights two sobering facts that may not be readily apparent as we care for patients. Fact 1: Middle class Americans have shifted nearly 25% of their income to covering healthcare costs between 2007 and 2014. This came at the expense of necessities such as food, housing, transportation, and clothing – all of which dramatically decreased. Fact 2: The average total cost of employer-provided healthcare coverage passed $20,000 for a family plan in 2019. In addition, the proportion covered out of pocket by families increased, while the proportion covered by employers decreased. These two facts emphasize that in the end, increased healthcare costs are passed on to our patients, most of whom cannot afford the care. Controlling healthcare costs begins with us in justifying every test we order, every operation we recommend, and every high cost item we use that doesn’t have clear clinical benefit. As costs continue to rise, our friends, neighbors, relatives, and patients are all bearing the burden.

Foregut

Article: Endoscopic duodenal mucosal resurfacing for the treatment of type 2 diabetes mellitus: one year results from the first international, open-label, prospective, multicentre study. Gut. 2019 Feb;69(2):295-303 Epub 2019 Jul 22. https://www.ncbi.nlm.nih.gov/pubmed/31331994

Dr. Manoel Galvao Neto: Endolumenal duodenal mucosal resurfacing (DMR) is a new concept on treating diabetes and metabolic conditions like NASH that is receiving a lot of attention and is really worth checking out. This is an international multi-centre, open-label study of 36 subjects on stable oral glucose-lowering medication who underwent DMR. The study, which was published in a high impact journal, reveals at 24 weeks post-DMR a significant drop in HbA1c (-10±2 mmol/mol (-0.9%±0.2%), <0.001), FPG (-1.7±0.5 mmol/L, <0.001) and HOMA-IR i (-2.9±1.1, <0.001), with the weight modestly reduced (-2.5±0.6 kg, <0.001) and hepatic transaminase levels decreased. This study finds DMR to be a safe endoscopic procedure that resulted in “durable glycemic improvement in sub-optimally controlled T2D patients using oral glucose-lowering medication irrespective of weight loss.”

Introduction

This month’s issue features an interview with our MISS Co-Directors and 2020 Faculty Bradley Davis, Scott Shikora, and Jaime Ponce. These thought leaders devoted their time to discuss teaching and training our residents on multiple platforms, 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 New Year from all of us at MISS!

–Colleen Hutchinson

What are the most effective tools in teaching and training today, in a climate and environment where there are multiple surgical approaches to learn?

Dr. Scott Shikora: I have come to believe that adequate training cannot be performed with a single tool or modality.  Due to the complexity of bariatric surgery and the ever-growing number of interventions that can be offered, the trainee must rely on many tools.  For example, surgical trainees need to be able to perform open, laparoscopic, robotic, and endoscopic techniques.  Therefore, unlike surgery in the past, where all skill development was done in the operating room by an attending who took a resident through the case, today’s surgeons—and those of the future—will need to also spend time in the skills lab putting hours into acquiring appropriate skills with endoscopes, robots, and laparoscopes.  In addition to simulation, the resident of today has access to massive libraries of published articles and videos that can also be of value for training.

Dr. Brad Davis: Experience in the operating room continues to be the most effective way to train residents on surgical techniques, which demonstrates how far behind we are from most skill-based industries. Simulation is an adjunct but is not yet good enough or affordable to offer any considerable boost in performance. What are needed are better tools at the front end to help medical students understand their aptitude for a career in surgery. The conventional wisdom of my mentors was that “I can train anyone how to operate.” That is simply not true anymore with the explosion in technologies and techniques and the subsequent strain on the learner to assimilate all of the skills necessary. Now more than ever we need better, higher fidelity tools to allow the learner to truly work in a virtual world. This technology has to be affordable and available to students and residents.

Dr. Jaime Ponce: I think the future of training will be simulators. As the technology improves, and many different case scenarios are incorporated, simulators allow surgeons facing a new technique and technology learn it, and then practice and practice before they can face a real patient. I think that is also one of the great advantages of robotic surgery, as this complex computer can simulate and allow residents and new surgeons to learn tasks like suturing, tying knots, dissection on difficult case scenarios, etc., much more easily. New devices and procedures will have to incorporate a simulation case scenario to enable easier learning of the tasks necessary to proceed in real patients.
 
What is the biggest challenge today in training residents?

Dr. Scott Shikora: I believe the biggest challenge to training residents is the lack of time available for training.  Residents have significant clinical responsibilities both in and out of the operating room that can potentially compromise the time necessary to adequately train.  This is exacerbated by the present work hour restrictions that leave many residents deficient in experience.  Additionally, the significant and growing requirements for documentation further reduce the time available for training.

Dr. Brad Davis: In the last 20 years, the surgical workforce and resident compliment has become more diverse – which is to the betterment of our patients and our specialty. However, we have not adapted to the diversity of learning styles and aptitudes. The time-based, quantitative nature of training is no different than it has been for the last 100 years. None of this takes into account the unique skills and needs of our learners. We need better assessment tools to understand where each resident is along his or her individual learning curve and eliminate metrics like number of cases to secure a graduation certificate. With tools like the “black box” in the robotics platforms, we can start to get more objective data on resident performance in skills acquisition and can develop a predetermined competency level, which would allow a resident to be “credentialed” doing a certain procedure. These tools need to be more widespread and available in all of our MIS and open platforms. The ability of a surgeon to objectively score a resident’s performance is varied, and we need to do better to ensure that all of our residents achieve the appropriate competencies.

Dr. Jaime Ponce: The biggest challenge is the need to be “productive” and “efficient” in a day, with different distractors including EMRs and OR time. Teaching includes dedicating time to allow the residents to perform tasks and techniques of all or part of the procedure, and initially will imply spending more time to teach and correct the residents while doing their first cases. That is why I think that simulators will be the future for residents to repeatedly practice before they face real patients for the first time, and this will allow them to improve their skills and ability to be more efficient in their learning curve on patients.
 
Has social media become more of an educational tool than a weapon for practicing general surgeons who seek to learn new techniques and procedures?

Dr. Jaime Ponce: Social media can be an educational tool, but it is important to understand that the book step-by-step will not be there for the most part. It will be an interesting tool for learning refining points, facing unusual cases, handling difficult situations, and maybe learning the highlights of new techniques. But learning surgery still as of today requires face-to-face with a teacher, additional tools like animal lab or cadaver assistance, and simulators.

Dr. Brad Davis: I am not sure how social media is playing out in terms of surgeons learning a new technique or procedure. I think it is valuable to have resources for surgeons to converse and be exposed to expert level performances, but watching a clip of an expert performing a complex case does not substitute for proper training and credentialing. Social media is not peer-reviewed.

Dr. Scott Shikora: Social media has become both an educational tool and a weapon for practicing general surgeons who seek to learn technique and procedures.  While there is a wealth of information in social media that may be of benefit, social media is unregulated and the contents are not peer-reviewed. Therefore, general surgeons seeking to learn new techniques and procedures may be exposed to biased material and data, or even be encouraged to perform procedures above their skill sets.

Suggested Readings

Endoscopy/General

Article: Safety and short-term effectiveness of endoscopic sleeve gastroplasty using overstitch: preliminary report from a multicenter study. Neto MG, Moon
RC, de Quadros LG, Teixeira AF, et al. Surg Endosc. 2019 Oct 17. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/31624939

Dr. Galvao Neto: Endoscopic sleeve gastroplasty (ESG) is an endobariatric therapy that is gaining traction worldwide as a treatment for obesity with promising results on safety and efficacy. In this new article, some of the Brazilian experience with the method is presented with 233 patients with Class I and II obesity, mean age and BMI of 41.1 years and 34.7 kg/m 2 , respectively, and a population of 73% female. The 123 patients who reached a 12-month follow-up had a mean 19.7% total weight loss (TWL). Safety analysis of the whole series reveals only one serious adverse event and no reported deaths. While ESG published literature presents quite some variation on suture pattern, this paper is based on the experience of a group of physicians trained by a single proctor that used the same technique in all cases. Gathered global experience on ESG allowed at least four meta-analyses to be published, and series like this one reinforce its promising results. An FDA randomized controlled trial is currently being performed to solidify it.
(https://clinicaltrials.gov/ct2/show/NCT03406975?term=merit+trial&amp;draw=2&amp;rank=1)

Colon

Article: Predictive factors and risk model for positive circumferential resection margin rate after transanal total mesorectal excision in 2653 patients with rectal cancer. Roodbeen SX, de Lacy FB, van Dieren S, et al. Ann Surg. 2019 Nov;270(5):884-891.
https://www.ncbi.nlm.nih.gov/pubmed/31634183

Dr. Alexander Hawkins: Transanal total mesorectal excision (TaTME) has been recently developed to increase the quality of surgical resection and improve oncological outcomes, particularly in patients with low rectal cancers. So how are we doing? This study looks at 2,653 patients out of a prospective registry and finds an outstanding overall circumferential resection margin (CRM) positivity rate of just 4%. A positive CRM after TaTME was significantly associated with tumors located up to 1 cm from the anorectal junction, anterior tumors, cT4 tumors, extra-mural venous invasion (EMVI), and threatened or involved CRM on baseline MRI. These are all features that we would expect to threaten any CRM regardless of technique. While the potential for selection bias exists in this study, the data overall shows that we are on the right track with this technique.

Foregut

Article: Does sleeve gastrectomy expose the distal esophagus to severe reflux?: a systematic review and meta-analysis. Yeung KTD, Penney N, Ashrafian L, Darzi A, Ashrafian H. Ann Surg. 2019 Mar 20.  [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/30921053

Rees Porta: Authors from the United Kingdom performed a meta-analysis on 46 studies from 2000 – 2018 which included 10,718 patients. While a meta-analysis won’t answer the questions of etiology or prevention, it does give good numbers for counseling patients. They showed de novo GERD in 20% of patients, worsening of GERD in 19%, esophagitis in 28%, and Barrett’s in 8% despite a mean EBWL of 61%. Interestingly, endoscopic findings of esophagitis and/or Barrett’s did not correlate well with symptoms.

Bariatric

Article: Mortality after bariatric surgery: findings from a 7-year multicenter cohort study.
https://www.ncbi.nlm.nih.gov/pubmed/31564635

Dr. Robert Lim: This is a very exciting article as it lends more credence that bariatric surgery improves life expectancy in obese patients. While it does not have the long-term follow up of the Swedish obesity studies, it does address the fact that those studies were in a very homogenous society and perhaps less applicable to the general population. On the other hand, there is a very concerning finding of the higher than expected mortality at 5-7 years after surgery.

Introduction

This holiday month’s issue features an interview with our MISS Co-Directors Aurora Pryor, Bradley Davis, and Guy Voeller. These thought leaders devoted their time to discuss some issues surrounding emerging technologies, MISS 2020, the state of FDA clearance path, and work-related challenges.

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, especially our newest—Dr. Alexander Hawkins, from Vanderbilt University Medical Center’s Division of General Surgery, Colon & Rectal Surgery. Happy Holidays from all of us at MISS!

–Colleen Hutchinson

What has been one of your biggest work-related challenges this year and how have you addressed it?

Guy Voeller: I am a busy clinical surgeon, so I operate 5 days a week with office hours 2 half days. When my day is done and I have rounded and tucked everyone in for the night, I go home and sit down at the computer to do billing for the day and to get charts ready for the next day. The scourge of the EMR! My biggest challenge is thus finding enough time to complete the day and be ready for the next. I think this is a problem for all busy surgeons today and I have not figured out a way to address this problem.

Brad Davis: One of the biggest challenges we face in our healthcare system is the increasing utilization of the hospital resources. We are strained in terms of OR availability and hospital beds. I believe this is an increasing trend as populations of large cities grow and the infrastructure has not kept up. In addition, patients are presenting with more complexity and minimally invasive surgery remains an important aspect of their care – it just takes longer and as such further puts a strain on resources.

Aurora Pryor: This has been a year of mastering work-life-society balance for me as President of SAGES. I am very lucky to have great partners in all three that have helped to enable my success (Thank you!!!). I think growing your support systems in lighter years enables you to keep up when you have less flexibility.

What about the specific MISS program that you oversee as Co-Director will be valuable to attendees?

Brad Davis: For the Colon program, we have a lot of great content as always. There have been several new publications related to bowel preps and the role of enhanced recovery in colorectal surgery, with a recent update from the ERAS society. In addition, we will discuss robotics and its role in colorectal surgery, as well as what’s new coming down the pipeline of innovation that will benefit our patients.
 
Guy Voeller: The Hernia session of MISS again has the leading authorities in herniology as faculty. We have an interesting session on coding and billing to properly maximize reimbursement, another session on whether Botox for hernia repair is a fad or here to stay, an excellent “debate” on robotics in hernia repair, and many other great sessions. It promises to have all the energy and controversy for which it’s become known.

Aurora Pryor: MISS is a great meeting to think a bit outside of the box from more mainstream meetings. We are getting to focus on clinical care and new opportunities in Foregut. I think every surgeon will find something new to bring home and implement from the meeting.

What are the most promising emerging technologies and/or techniques and procedures that you are excited about in your area of surgery?

Aurora Pryor: I have started incorporating a falciform flap into some of my more difficult paraesophageal hernia repairs. At a time and in a location where the use of mesh is questioned, a nice native tissue alternative for tissue reinforcement is appreciated. Fred Brody and Adrian Park introduced this technique to me, and I think it should be in the toolbox of every foregut surgeon.

Brad Davis: Always looking to see what the newest robotic platforms are going to bring. In addition to creating a more competitive market, which should help drive down costs, the partnerships currently out there have great potential to begin solving the next big problems. Machine learning and predictive analytics built in to some of these platforms will allow for greater safety and better outcomes.

Guy Voeller: In my area of surgery (general), it appears most of the focus on emerging technologies centers around robotic platforms and virtual reality for surgery. When these technologies are combined in an effective way, it will lead to some tremendous changes in the way surgery is done. Apparently competition for the Da Vinci robot is around the corner, and it will be interesting to see how hospitals, surgeons, and training programs deal with this situation. I don’t know what promise the new platforms will hold, but it will be extremely disruptive to be sure.

How would you characterize the current climate and process of obtaining FDA clearance for such new advances?

Guy Voeller: I think the FDA is under scrutiny due to the number of lawsuits regarding permanent synthetic mesh products. All of the mesh companies are paying millions and millions of dollars to defend these lawsuits and there is no end in sight. The 510K process has led to this problem. The Europeans now must go through a much more rigorous process for device approval that will require expensive clinical studies in order to obtain a CE mark (certification mark) to sell new products. I can foresee something similar coming to America. I think this will lead to significant changes in new technology introduction. Some of this will be good and some of it will be bad. The “climate” is thus a
hot mess.

Aurora Pryor: There has been some progress in getting new technology through the FDA, but I am frustrated that some new and effective technologies are struggling to gain traction (and reimbursement) after approval. I am working with SAGES this year to try to improve the reimbursement pathway for new technologies. These things help our patients by offering less invasive or more effective care. If we want to improve on what we do, this process must be optimized.

Suggested Readings

Endoscopy/General

Article: Brazilian intragastric balloon consensus statement (BIBC): practical guidelines based on experience of over 40,000 cases. Neto MG, Silva LB, Grecco E, et al. Surg Obes Relat Dis. 2018 Feb;14(2):151-159. https://www.ncbi.nlm.nih.gov/m/pubmed/29108896/

Dr. Galvao Neto: Intragastric balloons are by far the oldest endobariatric therapy (EBT), with around 20 years of clinical practice outside the US, but were just recently (2015) FDA-approved in the US. This Brazilian balloon consensus paper gives us the opportunity to understand how this therapy performs in a clinical setup among experts. 40,000+ cases is an impressive number, and this consensus—done under Delphi method—solidifies the intragastric balloon method and its clinical practice with regard to patient selection, preparation, multidisciplinary approach, technique, results and complications. The paper also serves as a guideline of practical recommendations for achieving good results.

Colon

Article: Intracorporeal or Extracorporeal ileocolic anastomosis after laparoscopic right colectomy: a double-blinded randomized controlled trial. Allaix ME, Degiuli M, Bonino MA, et al. Ann Surg. 2019 Nov; 270(5):762-767. https://www.ncbi.nlm.nih.gov/pubmed/31592811

Dr. Alexander Hawkins: An intracorporeal anastomosis after laparoscopic right hemicolectomy has a number of theoretical advantages- decreased hernia rate from the opportunity to place the extraction site anywhere in the abdomen, less mesenteric traction, and the ability to easily perform in iso-peristaltic anastomosis. This trial randomized 140 patients to either intra- or extra- corporeal anastomoses after a laparoscopic right hemicolectomy. Powered to compare length of stay (median of 6 days in this European study), they observed earlier recovery of postoperative bowel function in the incorporeal group, but no difference in length of stay. No other pathological or clinical differences were observed. Somewhat ominous was the non-significant difference in leak rate (Intra-8.7% vs Extra-2.9%; p=0.27). Overall, this is a well-done study that does little to settle the debate.

Hernia

Article: Lightweight mesh is recommended in open inguinal (Lichtenstein) hernia repair: A systematic review and meta-analysis. Bakker WJ, Aufenacker TJ, Boschman JS, Burgmans JPJ. Surgery. 2019 Oct 28. [Epub ahead of print]  https://www.ncbi.nlm.nih.gov/pubmed/31672519

Dr. Luke Funk: The type of mesh a surgeon uses during an open inguinal hernia repair with mesh (Lichtenstein technique) may influence recurrence and inguinodynia rates. In this study, the authors conducted a meta-analysis that included data from 21 randomized controlled trials studies and more than 4,000 patients. The investigators found that use of lightweight mesh (&lt;50 g/m 2 ) compared to heavyweight mesh (&gt;70 g/m 2 ) reduced the risk of experiencing “any pain” after hernia surgery and the risk of experiencing a foreign body sensation. There were no differences in recurrence rates or severe pain rates between the two groups. The authors concluded that lightweight mesh is preferred for open inguinal hernia repair with mesh. These findings are notable given that the Lichtenstein repair is the most common type open inguinal hernia repair performed.

Bariatric

Article: Eating self-efficacy as predictor of long-term weight loss and obesity- specific quality of life after sleeve gastrectomy: A prospective cohort study. Fiolo TN, Tell GS, Kolotkin RL, et al. Surg Obes Relat Dis. 2019 Feb;15(2):161-167. https://www.ncbi.nlm.nih.gov/pubmed/30709748

Dr. Robert Lim: This is an important paper that shows how eating behaviors affect bariatric surgery success. It is something that bariatric surgeons have felt all along but there is scarce literature on this topic. Not only does better eating self-efficacy lead to more weight loss, it also appears to allow for more durable weight loss.

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