MISS eNEWS
Improving Patient Outcomes with Minimally Invasive Surgery
Each month, MISS eNews brings you the latest on novel minimally invasive techniques and findings from around the world.
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MISS NEWSVol. 8 No. 49 |
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 IntroductionFirst 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!
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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 4th 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.
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Suggested ReadingArtificial IntelligenceArticle: Artificial Intelligence in Surgery: Promises and Perils. Hasimoto DA, Rosman G, Rus D, Meireles OR. Ann Surg. 2018 Jul: 268(1):70-76. 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. Robin Blackstone: Please see interview response above for feedback and insights on this article topic.
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BariatricArticle: 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. 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.
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MISS NEWSVol. 8 No. 48 |
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IntroductionDon’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!
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Interview with Dr. Mary HawnColleen: 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? Colleen: Do you foresee challenges in implementing components of the Stanford algorithm elsewhere? Colleen: What has been the most challenging thing for you personally in your surgeon role during the COVID pandemic? Colleen: Do you think that coming out of this pandemic, there will be permanent improvements in certain processes, protocols, and patient care?
Dr. Hawn’s JACS article can be read in full here.
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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 IBC Hot Topics in Surgery Webinar: Covid-19, Thrombosis & Bariatric Surgery Webinar—Watch here: The New England Journal of Medicine article: Multisystem Inflammatory Syndrome in U.S. Children and Adolescents 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. The New England Journal of Medicine Article: Genomewide Association Study of Severe Covid-19 with Respiratory Failure: IBC Hot Topics in Surgery Webinar: The Psycho-Sexual impact of Bariatric & Metabolic Surgery - Uncovering the Truths—Watch here: AIS Channel: 5 Things You Should Know About Watch & Wait Strategy for Rectal Cancer
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Suggested ReadingBariatricArticle: 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. 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
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MISS NEWSVol. 8 No. 47 |
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IntroductionDon’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!
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Interview with Delia Cortés GuiralColleen: 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? 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? Colleen: How has COVID-19 affected your specialty and how have you adapted? 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? Colleen: What are the main takeaways of the publication regarding COVID-19’s impact on colorectal surgery? Colleen: How has COVID-19 affected your specialty and how have you adapted? 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?
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MISS E-News COVID Resource Center: Link to these!AIS Channel: Care for the Cancer Patient with Heidi Nelson AIS Channel: The impact on surgical journals with Susan Galandiuk Surgical Endoscopy article: COVID-19 and impact on peer review American College of Surgeons Bulletin: ACS COVID-19 Update 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. ASMBS position statement entitled, "Safer Through Surgery," published online in the journal SOARD: IBC COVID-19 Webinar: Redefining New Standards in Metabolic Medicine & Surgical Research—Watch here:
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Suggested ReadingBariatricArticle: 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. |
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MISS NEWSVol. 8 No. 46 |
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IntroductionDon’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
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Interview with Dr. Gary Procop & Dr. Mariana BerhoColleen: How would you characterize the reliability of testing of COVID-19 currently—diagnostic molecular and diagnostic antigen, and antibody tests? 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? Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery or other in-hospital treatment? Colleen: Do you think that all staff at a medical institution should be tested for COVID-19?
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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 Surgical Endoscopy article: Detect to protect: pneumoperitoneum gas samples for SARS-CoV-2 and biohazard testing American College of Surgeons Joins New Surgical Care Coalition: ASMBS Webinar: Keeping Your Patients Engaged During the COVID-19 Crisis & Care for the Caregivers to Avoid Professional Burnout OR Management News Article: Key Steps to Regain OR Capacity After COVID-19 SAGES Guidelines: Safe Cholecystectomy Multi-Society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury during Cholecystectomy IBC COVID-19 Webinar: How Extended Reality (XR) Can Have a Positive Impact on Surgical Education During the COVID-19 Pandemic—Watch here:
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Suggested ReadingsBariatricArticle: Micronutrient Intake and Biochemistry in Adolescents Adherent or Nonadherent to Supplements 5 Years After Roux-en-Y Gastric Bypass Surgery. 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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MISS NEWSVol. 8 No. 45 |
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IntroductionHave you checked out 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 also archived for your convenience. It’s a fantastic way to get your CME in right from your home and with superior content that historically has only been available to those willing to travel to it! If you want to view the live events of this past week, including Tuesday 6/9 Best of Colon and Thursday 6/11 is Best of Hernia, 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. Tim Miller, President of ASER, who opined on Virtual MISS 2020, key MISS enhanced recovery takeaways, COVID-19’s impact on anesthesia and enhanced recovery, standards for opioids, and preop COVID testing. This week I speak with Dr. Francesco Rubino, a world-renowned surgical expert on the pathophysiology of diabetes and obesity, and the anti-diabetes effect of bariatric procedures, and MISS 2020 Faculty. Dr. Rubino and I discuss the 2020 MISS and the power of a quality meeting in-person and online, current COVID publications and the process of 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. I’d like to thank Dr. Rubino 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. Check them out, and especially don’t miss the Annals of Surgery Brief Clinical Report and the call to volunteer via the ACS Operation Giving Back. **Don’t forget to link to the Virtual MISS 2020 Symposium here!** Stay safe and check back next week for more!
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Interview with Dr. Francesco RubinoColleen: With MISS 2020 approaching and as we look to celebrate its 20 th anniversary, what do you anticipate for it being conducted as an online meeting and what do you think will be most valuable to attendees online? Colleen: On Twitter, you recently raised an important issue on current COVID publications and peer review. Specifically, you tweeted: According to the New York Times, greater than 10,000 scientific articles on COVID-19 have been published since January. Of them 3,500 are "preprints" with no peer-review. Pre-prints share time-sensitive data, which is useful in a pandemic. The issue is: how much bad science is there in 3,500 papers? How would you answer your own question? Colleen: What were the main recommendations shared in your Diabetes Surgery Summit-COVID- 19 Webinar, Recommendations for Bariatric/Metabolic Surgery in Times of Coronavirus and Beyond? Especially in terms of criteria for prioritization? After publication of our DSS recommendations, we have seen an initial polarization in our field, with some surgeons endorsing the DSS principles and others suggesting that we should instead prioritize patients with less burden of disease. I am particularly concerned that the latter approach may seem intuitive or desirable to reduce the risk of in-hospital infection in patients at plausibly greater risk of severe COVID-19, but in reality, it is a misconceived idea for many reasons. For one, this strategy would de-prioritize patients with greatest need, for whom delaying surgery will certainly cause harm from progression of their disease. It would be, in my opinion, both medically and ethically questionable if we tried to use very limited resources to expedite treatment of patients who would receive no harm if their surgery is postponed. Furthermore, this strategy would undermine the chances of our patients to have access to treatment when competing for limited space with other surgical specialties where surgeons traditionally use prioritization criteria based on objective urgency of treatment. Any patient with pain, or any level of risk of progression of disease will be – rightly – felt to have greater priority. Finally, I believe the exit from lockdown and the re-start of elective surgical services will be a defining moment for our field. If we, as a community of bariatric/metabolic surgeons, can show the severity of diseases that we treat with our procedures and the urgency these diseases represent, we will raise awareness of the lifesaving implications of bariatric/metabolic surgery. On the contrary, pushing to expedite treatment in patients with no risk of harm from delay will reinforce the widespread misconception that bariatric/metabolic surgery is optional, or a treatment with the same priority level of a cosmetic procedure. The next few months will be critical, and we bariatric/metabolic surgeons have a huge responsibility: the way we respond to this pandemic could either promote the image of bariatric surgery as an evidence-based, lifesaving treatment or reinforce stereotypes and prejudice. It is up to us to rise to the challenge. Colleen: In past issues, we have talked about necessity being the mother of invention, and COVID’s impact on several facets of healthcare. What is COVID-19’s impact in the UK comparatively speaking on the following—in a few words:
Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery? Colleen: Do you think that laparoscopy should be used in patients with COVID-19? Colleen: Do you think that negative pressure operating rooms are critical for surgery in patients with COVID-19?
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MISS E-News COVID Resource Center: Link to these!Annals of Surgery Brief Clinical Report (Online only): Social Media Responses to Elective Surgery Cancellations in the Wake of COVID-19 ACS Operation Giving Back: COVID-19 Medical Workforce Volunteers Needed. ASMBS Webinar: COVID-19 Town Hall Q&A: Restarting Surgery – Issues to Consider In Prioritizing Cases SAGES Guidelines: SAGES primer for taking care of yourself during and after the COVID-19 crisis IBC COVID-19 Webinar Tuesday, June 16: Back to the Future.
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Suggested ReadingsBariatricArticle: Safety of adjustable gastric band conversion surgery: a systematic review and meta-analysis of the leak rate in 1- and 2-stage procedures. Zadeh J, Le C, Ben-David K. Dr. Jaime Ponce: This is the latest meta-analysis on the band conversion surgery data, which is the most common revisional bariatric procedure. This review analyzes the differences in safety outcomes between 1- and 2- stage conversions in 25 publications. The overall results showed that there is no significant difference in the leak rate between 1- and 2- stage approaches, and this may be different to initial analysis showing increased rates. The conversions and the ability to create a stomach stapled pouch dealing with the scar tissue has improved and in my opinion the learning curve has proven to be a major factor to decrease complications in these difficult cases.
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GeneralArticle: The new weight-loss drugs, lorcaserin and phentermine-topiramate: slim pickings? Woloshin S, Schwartz LM. JAMA Intern Med. 2014 Apr;174(4):615-9. Dr. Steve Nissen: This review in JAMA Internal Medicine highlights the limited efficacy of weight loss drugs. |
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MISS NEWSVol. 8 No. 44 |
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IntroductionWe 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. Jo Buyske, President and CEO of the American Board of Surgery. This week I speak with Dr. Timothy Miller, MISS 2020 Faculty and President of the American Society for Enhanced Recovery, from Duke University School of Medicine. Dr. Miller and I discuss what Virtual MISS 2020 will be like, what MISS enhanced recovery takeaways will be, COVID-19’s impact on anesthesia and enhanced recovery, the standards for enhanced recovery regarding opioids, and preoperative testing for COVID. We end with the ASMBS application for a focused practice designation in metabolic and bariatric surgery. I’d like to thank Dr. Miller 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. Check them out, and especially don’t miss the new ACS Patient Surgery Toolkit—a new post-COVID-19 resource to help you and your hospital address patient concerns. **Don’t forget to link to the Virtual MISS 2020 Symposium here!** Stay safe and check back next week for more!
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Interview with Dr. Timothy MillerColleen: With MISS 2020 approaching and as we look to celebrate its 20 th anniversary, what do you anticipate for it being conducted as an online meeting and what do you think will be the most important takeaways from MISS2020 regarding enhanced recovery for surgeons to learn and understand? Colleen: As President of ASER, you are uniquely positioned to update readers on what’s new in enhanced recovery. Can you summarize current updates for MIS surgeons that have recently taken place and will move the needle forward on best practices in patient care? Colleen: How has COVID-19 affected your specialty and how have you adapted? Colleen: What standards are being or have been implemented for enhanced recovery regarding opioids? Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery?
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MISS E-News COVID Resource Center: Link to these!ACS: New Patient Surgery Toolkit! Preparing to Have Surgery During the Time of COVID-19 SAGES Coronavirus Global Surgical Collaborative (CVGSC) Initiative & Summary ASMBS Webinar: Independent/Community Practices: Surviving COVID-19 IFSO on COVID-19 article in Obesity Surgery: IFSO Recommendations for Metabolic and Bariatric Surgery During the COVID-19 Pandemic Journal of the American College of Surgeons Article: Ethics in the Time of Coronavirus: Recommendations in the COVID-19 Pandemic And a reply to above article:
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Suggested ReadingsBariatricArticle: Bariatric surgery-induced cardiac and lipidomic changes in obesity-related heart failure with preserved ejection fraction. Mikhalkova D, Holman SR, Jiang H, Saghir M, Novak E, Coggan AR, O’Connor R, Bashir A, Jamal A, Ory DS, Schaffer JE, Eagon JC, Peterson LR. Obesity 2018; 26(2):284-290. Dr. Tammy Kindel: This article, as mentioned at the 2020 MISS meeting, reports on a small cohort of patients with heart failure with preserved ejection fraction examined echocardiographic measurements, lipid cardiac and liver deposition, and heart failure related symptoms. The first published report on heart failure with preserved ejection fraction patients undergoing bariatric surgery, the authors found a significant improvement in heart failure symptoms, reverse detrimental cardiac remodeling, and improved cardiac relaxation, a hallmark of HFpEF. Although small in sample size, the ability to impact HFpEF related cardiac function and symptoms given the current lack of successful pharmacotherapy in HFpEF is an important step forward in metabolic surgery.
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GeneralArticle: Millennium Generation Poses New Implications for Surgical Resident Education. Wall J. Source: American College of Surgeons Resources in Surgical Education. Dr. Robin Blackstone: Dr. Wall illustrates the effect of culture on training different generations of surgeon trainees. The expectations of life and work are different and important aspects as well as how residents will learn. This is a great mind-opening short article for anyone who is in the midst of training. |
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MISS NEWSVol. 8 No. 43 |
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IntroductionWe 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 Steven Wexner on COVID and colorectal surgery, the ACS COVID communications resources, his recent COVID publication, and what the new normal will be for elective surgery. This week I interviewed Dr. Jo Buyske, President and CEO of the American Board of Surgery. It’s an interesting time to talk with Dr. Buyske, given that she oversees the ABS and is leading the charge to innovate during these challenging times. Under her leadership, the ABS 2020 General Surgery Qualifying Exam will now be offered virtually as a web-based, live-proctored, at-home examination in July. We discuss COVID-19’s impact on the ABS, its major impact on the profession of surgery moving forward, its impact on residents’ and fellows’ learning and training, the future of surgical training and specialization, and the role of the non-specialist general surgeon in today’s age. We end with the ASMBS application for a focused practice designation in metabolic and bariatric surgery. I’d like to thank Dr. Buyske for taking this time to discuss these topics and more for the MISS E-News. We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. This week’s resources include the JACS article: Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID-19 Pandemic, ACS post-COVID economic survival strategies guide, SAGES new free webinar on thriving in surgical practice post-COVID, IBC Channel’s latest COVID webinar, ASMBS’s new webinar: Keeping Your Patients Engaged During the COVID-19 Crisis & Care for the Caregivers to Avoid Professional Burnout, and the ACS new Entering Resident Readiness Assessment (ACS ERRA) program—a great tool post-COVID-19 to ascertain thepreparedness of entering residents and identify gaps. **Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here!**
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Interview with Dr. Jo Buyske—President & CEO of the American Board of SurgeryColleen: In past issues, we have talked about necessity being the mother of invention, and new uses of technology such as telemedicine and virtual reality creating more touch points with patients and practice management support during this pandemic. Dr. Buyske: The ABS, like so many other companies, has been tremendously impacted by the pandemic. Really all arms of our organization, including office operations, our core work of exam delivery, and the governance functions of the ABS moved quickly to comply with travel bans, shelter in place orders, and CDC guidelines against gatherings. Our office went to 100% work from home on March 17 th . That has been nearly seamless for our surgeon constituents, since we are still answering phones and emails, but it has been a huge culture change for the office. They have done incredibly well at staying productive in an unstable environment. To our candidates, I’m sure the biggest changes have been the impact on our oral (certifying) exams and written (qualifying) exams. We cancelled general surgery certifying exams in April and June, and the vascular surgery certifying exam in May. We immediately offered all of those disappointed candidates first choice of exam dates for next year’s exam so they could be assured that they would stay on some sort of career timeline, but we also rapidly implemented a video-based oral exam as a small, proof of principle pilot. On May 19 and 20 we delivered the first pilot to 17 people. It was a highly resourced exam, with three examiners and a staffer for each set of candidates. No exam had to be cancelled or invalidated, and we had a pass rate that was consistent with historic norms. A post-exam survey showed a very high degree of satisfaction from the candidates. We will repeat the pilot in a near identical model with a larger group of people on June 2 and 3. After that we will need to pause, address lessons learned, and figure out what we are going to do with the 2000 or so candidates who need to be certified in the upcoming academic year. Regarding the written exam, our exam centers were struggling with capacity issues due to social distancing requirements that varied from state to state. We did not want our candidates to be subjected to cancelled reservations or any kind of flux, and we were also reluctant to be responsible for people having to either travel or to gather in a testing center. We used a vendor that we already use for the in-training exam and the continuous certification exam, and they helped us quickly convert from the traditional, 8-hour, 1-day exam at a testing center to a 2-day, at-home, remote proctored secure exam. We felt strongly that that was the best thing for our surgeon candidates. I think that from a leadership point of view, we have grossly underemployed video technology. From our exams to telehealth to virtual meetings, it appears that the world of surgery and healthcare rolls on without airplane flights, days away from work, travel, hotels, and meals. I do think something has been lost by losing the face to face, but it has been incredibly instructive to move so abruptly to virtual interactions, and in many ways we will not go back. This public health crisis accelerated needed change. What is COVID-19’s impact on residents’ and fellows’ learning and training? Dr. Buyske: I have to say that that remains to be seen. We know that surgical trainees spent less time in the hospital on surgical services. Residents were kept at home in bullpens, or clean teams, or they were quarantined, or they were sick. The surgical census in hospitals dropped dramatically, so there were fewer cases and fewer consults as well. The overall clinical exposure, across all surgical specialties and all years of training, is significantly diminished. That being said, this is a once in a lifetime opportunity for residents to really step up to leadership and crisis management, participate in surge capacity planning, manage scarce resources, and be creative with technology. They’ve had to take responsibility for their own learning with meetings and conferences cancelled. It has been a remarkable event, and I’m proud of the way they have stepped up to the plate. Colleen: What’s the future of surgical training? Will it be 2 to 3 years of general experience and then 2 to 3 years specialty training such as foregut, colorectal, hepato-pancreato-biliary, and bariatric? Dr. Buyske: I’m not sure I am smart enough to know the future. There are a lot of successful models for training surgeons all over the world, and some of them are as you describe, and produce very good surgeons. At the moment we are focused on acquisition of skills and knowledge, and less on measuring months of training. We are in the last month of a feasibility study for Entrustable Professional Activities (EPA), which would be a new paradigm in formative resident assessment, culminating in summative decisions. It requires multiple microassessments by multiple individuals at different points in time. As is so often the case, the whole is greater than the sum of the parts. The power of EPAs lies in the multiple assessments. This requires a change in thinking on the part of both the trainees and the trainers. Nevertheless, the ABS board of directors voted to march forward with writing the entire portfolio of EPAs that would encompass general surgery training, and to start to implement it as the tool of advancement in training in 2023. Right now, using our Flexibility in Training (FIT) option, a few trainees have shortened their training. Through FIT, a resident can customize up to 12 months of the last 3 years of training, which in some cases can then count towards fellowship. So modular training is possible…it just isn’t our current focus. Colleen: The Journal of Surgical Research just published a new article, “Underrepresented in Surgery: (Lack of) Diversity in Academic Surgery Faculty. Dr. Buyske: For topics like this one we must be relentless in focus. Keeping the subject in view by publishing, reporting, and documenting is a critical tool in the toolbox to rectifying this dysfunctional situation. Education and awareness are paths out of darkness. We also need to reexamine the metrics we use for advancement. The homogeneity of those descriptors needs to be evaluated. How helpful is it to have 20 people who came up through academic institutions, did a fellowship, work with residents, and have 200-plus publications serving on the same committee? Those are remarkable accomplishments and should be recognized, but bringing other skills and experience to the table is essential to being the best profession we can be. Colleen: Is there a role for non-specialist general surgeons anymore? Dr. Buyske: Absolutely, and I think that COVID has shown that. Surgeons were going back to core skills during the peak of this wave of the pandemic. Specialists were doing ICU care, MIS surgeons were doing open cases, and everyone was learning about ventilator management and PPE. The generalist became a valuable commodity. As surgeons were pulled into areas outside their field of specialty or expertise, someone still needed to manage the acute cases. It was very interesting and telling. We cannot afford to play taps for the general surgeon. Colleen: Can you share your thoughts on the new ABS special designation for bariatric surgery? Will there be board certification for bariatric surgery in the near future? Will there by a special designation for MIS as well? Dr. Buyske: I am very pleased that the ASMBS applied for a focused practice designation in metabolic and bariatric surgery. The application had to be vetted first through what used to be our Advanced Surgical Education Committee, then the full board of directors of the ABS, then a committee of the American Board of Medical Specialties (ABMS), and then the full board of the ABMS. It is not an easy process. Now we are working on operationalizing that process, including developing the first exam and eligibility criteria. We know that people who do large volume bariatric surgery and focus their practice in general have better outcomes, so this was a good place to start. Several other specialty groups have expressed interest, but at the moment we have no other active designations in the pipeline.
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MISS E-News COVID Resource Center: Link to these!ACS: New Approaches to Educating Surgeons of the Present and Future: Determine the Decision-Making Skills of New Residents with ACS Entering Resident Readiness Assessment (ACS ERRA) SAGES Free Webinar: Finding the Opportunities: Lessons from COVID and How We Live and Thrive as Surgeons ASMBS New Webinar: Keeping Your Patients Engaged During the COVID-19 Crisis & Care for the Caregivers to Avoid Professional Burnout Journal of the American College of Surgeons Article: Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID-19 Pandemic IFSO on COVID-19: "Enhancing Bariatric Patient Experience During COVID 19" ACS: Economic Survival Strategies in the COVID World: A Guide from the ACS Practice Protection Committee IBC Webinar: Covid-19 & the Healthcare Professional: Thinking Outside the Box
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Suggested ReadingsGeneralArticle: Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery (INPRESS): A Randomized Clinical Trial. Futier et al. JAMA. 2017 Oct 10;318(14):1346-1357 Dr. Tim Miller: The INPRESS trial was one of the first interventional studies aimed at individualizing perioperative blood pressure management. The study showed a reduction in complications in the intervention group that first had their fluid status optimized, followed by inclusion of a vasopressor to maintain blood pressure within 10% of baseline. This trial adds to the increasing evidence that even short duration of hypotension perioperatively, usually defined as a mean BP <65 mmHg, is associated with myocardial and kidney injury.
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BariatricArticle: Effects of Bariatric Surgery on Cardiovascular Function. Ashrafian H, le Roux CW, Darzi A, Athanasiou T. Circulation 2008; 118:2091-2102. Dr. Tammy Kindel: This review article highlights the complex interplay between obesity, obesity-associated comorbidities and heart failure development. Bariatric surgery through multiple mechanisms, including a reduction in system inflammation and adipokines as well as best treatment of obesity-associated comorbidities, results in improved cardiac function and reduction in heart failure symptoms. The contribution of the entero-cardiac axis to heart failure improvement after bariatric surgery is explored, including literature supporting the role of glucagon-like peptide-1. |
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MISS NEWSVol. 8 No. 42 |
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IntroductionWe are back in your inbox this week with a new MISS COVID-19 Surgeon Resource. Last week we gave you key insights from MISS 2020 Hernia Program Co-Director Guy Voeller and Colon Program Co-Director Brad Davis on how COVID’s impact on their hernia and colon surgery practices, how they are coping, and what restarting will look like. This week I spoke with Steven Wexner on COVID and colorectal surgery, the ACS COVID communications strategies, resources, and effectiveness, his recent COVID publication in Colorectal Disease, and what the new normal will be for elective surgery. We also discuss whether all patients should be tested for COVID-19 prior to surgery, and if laparoscopy should be used in patients with COVID-19. We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. This week’s resources include the ACS Post-COVID-19 Readiness Checklist for Resuming Surgery, SAGES summary on the impact of the COVID- 19 Pandemic on the conduct of surgical research, ASGE’s services guidance document for resuming GI endoscopy and operations post-COVID, General Surgery News article on COVID-care billing, IBC Channel’s webinar on COVID implications in obesity, diabetes, metabolic & cancer surgery, and more. We hope this week’s issue proves to be a critical source of key information for you to keep current during this challenging time. Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here.
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Interview with Dr. Steven WexnerWhat changes that have developed during COVID do you think will persist? How can surgeons improve patient care by using these changes?
Colleen: As an American College of Surgeons (ACS) Regent, can you tell us about the development, implementation and impact of the ACS’s extensive educational efforts including COVID-related guidelines, resources, your interviews, and the twice-weekly Bulletin: ACS COVID-19 Newsletter? I am doing video interviews with various doctors from around the world as well as ACS leaders, other surgical leaders, non-surgeon leaders, international colleagues, and surgeons who have been stricken with and fortunately recovered from Covid-19 to make sure that I have two to three videos per issue. The actual interviews have been written and are also going to be published in American Surgeon, so they'll be referenceable.
Colleen: Can you tell readers findings in your journal article “COVID‐19: Impact on Colorectal Surgery” in Colorectal Disease?
Colleen: What are some of the most difficult clinical challenges you are facing as a colorectal surgeon right now because of the virus?
Colleen: What will the new normal be for elective surgery?
Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery? Colleen: Do you think that laparoscopy should be used in patients with COVID-19?
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MISS E-News COVID Resource Center |
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ACS: American College of Surgeons Post-COVID-19 Readiness Checklist for Resuming Surgery (for online access and a printer-friendly version: SAGES: Impact of COVID-19 Pandemic on the Conduct of Surgical Research Journal of the American College of Surgeons Article: Fibrinolysis Shutdown Correlates to Thromboembolic Events in Severe COVID-19 Infection General Surgery News Article: Billing for COVID-19 Care—Getting Your 20% Medicare Add-on Payment for COVID-19 FDA Updates: Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions ASGE: COVID-19 Practice Operations Discussion Forum: Lessons Learned from the Initial Phase of Resuming Endoscopy Services ASGE: Services Guidance For Resuming GI Endoscopy And Practice Operations After The COVID-19 Pandemic IBC Webinar: Covid-19 & Implications in Obesity, Diabetes, Metabolic & Cancer Surgery
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Suggested Readings |
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General |
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Article: Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.
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Bariatric |
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| Article: Comparative analysis of robotic versus laparoscopic revisional bariatric surgery: perioperative outcomes from the MBSAQIP database. Nasser H, Munie S, Kindel TL, Gould JC, Higgins RM. Surg Obes Relat Dis. 2019 Dec 3. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/31932204 Dr. Jaime Ponce: Another great article from the MBSAQIP database. It gives us a landscape of the utilization of different techniques in revisional bariatric surgery, with only 7.8% of the revisional cases being done robotically. Robotics has been suggested as a tool to deal with more complex cases, and this is one factor that we cannot extract from the MBSAQIP database. The potential bias for taking the more difficult revisional cases to a robotic platform may be a potential factor for the longer operative time and increased complications in the revisional sleeve gastrectomy cases. It is well known that longer and more complex cases can have increased morbidity. Interestingly, the use of robotics in revisional gastric bypass cases didn’t increase operative time or morbidity when compared to conventional laparoscopic technique. Robotics in my perspective is a tool that when used in the right hands can assist in performance of more complex revisional cases. |
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MISS NEWSVol. 8 No. 41 |
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IntroductionWe are back in your inbox this week with a new MISS COVID-19 Surgeon Resource. Last week we gave you key insights from MISS 2020 Faculty Dr. Neil Floch and Dr. Elizabeth Dovec on telehealth during COVID and its future expanding role, with a specific focus on its impact on bariatric practice. This week we hear from Hernia Program Co-Director Guy R. Voeller, MD, and MISS Colon Program Co-Director Bradley R. Davis, MD, on how COVID has impacted their hernia and colon surgery practices, how they are coping, and what restarting will look like. We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. We hope this week’s issue proves to be a critical source of key information for you to keep current during this challenging time. Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here. Stay safe and check back next week for more!
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Interview with Dr. Guy Voeller & Dr. Brad DavisColleen: How would you characterize the virus’s impact specific to your area of surgery? Dr. Brad Davis: We were impacted, but we continued to perform surgery for cancer and symptomatic IBD. So our backlog was much less than those surgeons who were doing only truly elective cases – just as important but less time sensitive. The biggest impact was just on the workflow with no families and social support for the patients in the hospital; it is very hard for them.
Colleen: What will restarting your practice look like and how will it be different? Dr. Brad Davis: Virtual care is here to stay. It is just too big a value added for the patient. Restarting will be great and we are prepared. Teamwork is the key with everyone working together to get the patients scheduled and taken care of safely.
Colleen: What has been the most surprising thing coming out of COVID19 that is positive, from your perspective? Dr. Brad Davis: The use of virtual care platforms and the value that virtual care creates for patients without sacrificing safety and outcomes.
Colleen: What has been the most challenging thing coming out of COVID19, from your perspective? Dr. Guy Voeller: One of my sons needs a kidney transplant and my wife is the donor. Trying to determine when is the safest time for both of them to have a very serious operation and my son’s resultant immunosuppression during this viral outbreak has without question been the most challenging thing for me during this pandemic. We still have not made a decision due to all these issues.
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MISS E-News COVID Resource Center |
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ASMBS: COVID-19 Updates: Restarting Surgery - Issues to Consider in Prioritizing Cases VIDEO: General Surgery News Residents’ Experience as a Resident During the COVID-19 Pandemic: FDA Guidance Documents Related to Coronavirus Disease 2019 (COVID-19); Availability. Available at: https://www.federalregister.gov/documents/2020/05/12/2020-10146/guidance-documents-related-to-coronavirus-disease-2019-covid-19-availability Surgical Endoscopy article: SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic SAGES COVID-19 MEDICAL DEVICE REPOSITORY (inclusive of Commercially Available Smoke and Gas Evacuation Systems, N95 Facepiece Respirator Decontamination Systems, and COVID-19 Testing Products) ACS Bulletin: ACS COVID-19 Update Journal of the American College of Surgeons Article: Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID-19 Pandemic Article: Surgeons, Ethics, and COVID-19: Early Lessons Learned
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Suggested Readings |
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Foregut |
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Article: Systematic review of the introduction and evaluation of magnetic augmentation of the lower oesophageal sphincter for gastro-oesophageal reflux disease. Kirkham EN, Main BG, Jones KJB, Blazeby JM, Blencowe NS. Br J Surg. 2020 Jan;107(1):44-55. Dr. Luke Funk: Magnetic sphincter augmentation (MSA) surgery has existed as a treatment for GERD for nearly a decade. Advocates of this procedure note that is does not involve significant distortion of the gastric or hiatal anatomy and creates a durable strengthening of the LES mechanism. In this study, the authors conducted a systematic review of the literature and included data from 39 studies. The investigators applied the “IDEAL Framework” for assessing innovative surgical procedures and concluded that most studies did not include important data regarding patient selection, surgical technique, or surgical outcomes. Nearly two-thirds of the studies were case series, and only 1 was an RCT. None included information about the learning curve for surgeons, and no single outcome was measured in all studies. These findings are notable because several thousand devices have been implanted thus far and many more will likely be implanted. Additional data collection and rigorously conducted prospective studies are needed so surgeons can better understand the short- and long-term risks, benefits and outcomes of this procedure.
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Bariatric |
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Article: The True Story on Deficiencies After Sleeve Gastrectomy: Results of a Double-Blind RCT. Häuschen L, Schijns W, Ploeger N. Obes Surg. 2019 Nov 27. Dr. Dimitrios Pournaras: There has been a rapid rise in the popularity of sleeve gastrectomy in recent years and has now surpassed Roux en Y gastric bypass as the |
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MISS NEWSVol. 8 No. 40 |
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IntroductionAs your trusted resource for all things surgery and COVID, we are back in your inbox this week with a new MISS COVID-19 Surgeon Resource. The focus? Telehealth! This week, we provide you with key insights from MISS 2020 Faculty Dr. Neil Floch and Dr. Elizabeth Dovec, two surgeons who are considered major thought leaders in social media and related concepts. Here they share with you their thoughts on telehealth now during COVID challenges and its future expanding role in practice, with a specific focus on its impact on bariatric practice. We hope this week’s issue proves to be a critical source of key information for you to keep current during this challenging time. Don’t forget to register for our upcoming Virtual MISS 2020 Symposium here. Stay safe and check back next week for more!
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Interview with Dr. Elizabeth Dovec & Dr. Neil FlochColleen: Plato said: Necessity is the mother of invention. Right now, by necessity, virtual reality is creating more touch points with patients. We have seen telemedicine’s role in patient care and practice management grow exponentially during this pandemic. Dr. Floch: In times of dire necessity during the COVID-19 outbreak, doctors were strongly discouraged from seeing patients in-person to limit their exposure to the virus. 1 The US government implemented two rules that allowed for the rapid adoption of telemedicine technology: 1) allowance to use non-HIPAA compliant telemedicine platforms 2,3 and 2) insurance coverage for virtual visits. 2,3 These changes have the potential to dramatically change multiple facets of bariatric surgery patient care. Live webinars could become more accessible and convenient for marketing programs and the education of the preoperative patient. Patient compliance with postoperative visits could become more convenient as patients may be seen in the evening, at a break during work, and while caring for their young children. As technology advances, the reliance of a patient weighing him/herself may evolve into texting pictures of the scale or using “smart scales” that link to a surgeon’s electronic medical record. Long-term outcomes may improve as patients become more compliant with telemedicine visits. Reporting for centers of excellence requirements may become easier to fulfill as patients become more compliant. Dr. Dovec: While it took a global crisis for us to recognize the vulnerability of the outdated way we practice medicine, we now have an exceptional opportunity to incorporate technology into how we take care of patients. Currently, the pandemic has led to extensive limitations in surgical treatment of morbid obesity. Like the rest of the US healthcare industry, weight loss surgery (WLS) is structured on the historically necessary model of in-person interactions between patients and clinicians. Numerous variables hinder eligible people from seeking or progressing to surgery including lengthy, insurance mandated, preoperative, supervised weight loss. Using these unusual times as a catalyst, embracing digital education platforms as a novel and necessary long-term solution in bariatric preoperative education is needed. This tool holds great potential for the resource-limited setting that will follow the peak of the coronavirus pandemic. In the context of bariatric preoperative education, this platform has demonstrated equivalent preoperative outcomes along with decreased attrition and time to surgery. Subjectively, participants found it to be convenient and easily understandable. Although a traditional, in-person supervised weight loss program is required by many insurance companies, digital options improve access for patients, standardize the material delivered, and decrease preoperative obstacles. Finally, it offers an evidence-based, validated alternative to relax these insurance requirements. Patients who have been living with symptoms from complications of bariatric surgery such as ulcers, severe reflux, obstruction, and related chronic diseases, such as symptomatic gallbladder disease and hernias, will be addressed first. As obesity is a chronic condition that affects many medical issues and the length of life, bariatric surgery is not elective since it dramatically improves the obesity condition and a patient’s future risk of mortality from COVID-19. When considering all bariatric patients, those who are prepared for surgery will proceed next, followed by patients who have time-sensitive requirements. Many patients may need to repeat some of these requirements unless insurers accept them because of the COVID-19 pandemic. Colleen: Will a shift to telemedicine for any parts of practice require a shift as well in document/materials management, access, and storage? Dr. Dovec: We will no longer have the need to give patients lengthy binders and store them in the office setting. All documents can be housed on the website for easy access and sent through their electronic medical records. We estimate saving $12,000 annually in printing fees alone. We have long ago outgrown the physical space of our office. This has been rate-limiting in allowing us to grow beyond 1,300 cases performed annually. In addition to doing more surgeries by offering pre- and postoperative appointments virtually, this week we are launching a 100% virtual, comprehensive, postoperative medical weight loss program. Dr. Dovec: I never stopped my bariatric surgical office practice. Our practice decided to go 100% virtual and pushed through the challenges of change. I doubled down on my digital marketing efforts to improve visibility and enhance existing patient engagement. Following the trends, we have seen a significant return on investment with an increase in the number of new patients starting their virtual journey. The importance of creatively keeping the pipeline of surgical candidates interested is high. We are not just surviving; we are thriving by changing the game instead of trying to play the same old one. Dr. Dovec: Social distancing has allowed some of the telemedicine billing and coding rules to be relaxed. The way you bill an in-person new patient or established CPT code is the same for a video visit. In place of the comprehensive physical exam, you will now bill for face-to-face time spent through counseling and the coordination of care. For example, incorporating the information session where you explain the risks, benefits, and alternatives to surgical treatment into the virtual initial consult as a live group session prior to the private video visit increases face time with the surgeon and increases billing and coding levels. Research shows that doctors spending more time with patients see better medical outcomes. When doctors take time to make human connections—or to be compassionate, patient outcomes improve and medical costs go down. The more satisfied that patients are with the care you provide, the more likely they will refer their friends and family to you. Colleen: Time is money. And telemedicine increases access by breaking down barriers. What are the potential upsides for both the surgeon and patient with the use of telemedicine/virtual reality? Dr. Floch: Telemedicine is a major advantage to practices that can increase patient visits and reduce costs. The patient won’t need to drive to the doctor, park, walk distances when they are impaired, or take time off from work. Doctors will need less staff to see patients and may need smaller offices. They may be able to share space, which will reduce real estate costs and overhead. There will be the possibility to work from home. There can be better access after regular business hours and on the weekends. There will be better documentation as phone and virtual visits will be documented in electronic medical records. Dr. Dovec: There is mounting evidence that telemedicine can save patients and programs alike two things they value most: time and money. By simplifying the sign-up process, seeing patients on time for their initial consultation via video visit, providing online educational materials and support by connecting your patients with their peers on existing social media platforms, getting them set up with a standardized digital preoperative education platform (which often counts for the insurance-mandated preoperative requirements and offers free program patient tracking), doing the final preparation class and consultation virtually will all result in more patients having surgery. In summary, if we embrace telehealth now, we will undoubtedly lay the foundation to increase the 1%. |
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MISS E-News COVID Resource Center |
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ACS: New toolkit provides rapid implementation guide for adopting telemedicine during COVID-19 ASMBS Free Webinar—COVID-19 Updates: Embracing Telehealth SAGES Free Webinar – Surgical Guidelines During COVID-19 Novel Coronavirus Information Center: Elsevier’s free health and medical research on the novel coronavirus (SARS-CoV-2) and COVID-19 General Surgery News Article: Preparing for Overwhelmed ICUs by Leveraging Existing ORs, Anesthesia Machines and Perioperative Personnel—A Call to Action
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Suggested Readings and References from Dr. Neil Floch |
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1. Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program amidst the COVID-19 Pandemic. Journal of American College of Surgeons. DOI: 2. Centers for Medicaid Services. Anon: Medicare Telemedicine Health Care Provider Fact Sheet. 3. Benefits in Medicare are a Lifeline for Patients During Coronavirus Outbreak | CMS. 4. Hakim D and Singer N: New York Attorney General Looks Into Zoom’s Privacy Practices. 2020. 5. General Provider Telehealth and Telemedicine Tool Kit 6. Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic. Prachand VN, Milner R, Angelos P, et al. J Am Coll Surg. 2020;S1072-7515(20)30317-3.
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