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Time to embrace minimally invasive colorectal surgery?
LAS VEGAS – Two-thirds of colon resections in the United States are open procedures, but a colorectal surgeon told colleagues that evidence shows minimally invasive surgery deserves a wider place in his field.
Why? Because minimally invasive surgery – despite its limited utilization – is linked to multiple improved outcomes in colorectal surgery, said Matthew G. Mutch, MD, chief of colon and rectal surgery at Washington University, St. Louis, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“Our goal should be to offer minimally invasive surgery to as many patients as possible by as many different methods as needed,” Dr. Mutch said. “If you’re willing to take this on and do this over a regular basis, you’ll get over that learning curve and expand the number of patients you can offer laparoscopy to.”
According to Dr. Mutch, benefits of minimally invasive colorectal surgery include:
- Improved short-term outcomes – length of stay and return of bowel function, and morbidity and mortality. A 2012 retrospective study of 85,712 colon resections that found laparoscopic resections, when feasible, “had better outcomes than open colectomy in the immediate perioperative period.” (Ann Surg. 2012 Sep;256[3]462-8).
- Improved long-term outcomes: faster recovery, fewer hernias, and fewer bowel obstructions.
- Lower overall costs.
- Fewer complications in the elderly.
When it comes to laparoscopic colorectal surgery, Dr. Mutch cautioned that the robotic technology has unclear benefit in rectal cancer, and the cost in colorectal cancer is unclear.
Another alternative is to perform laparoscopic colorectal surgery through alternative extraction sites such as the rectum, vagina, stomach, and even a stoma site or perineal wound. Both transanal and transvaginal extraction are feasible and safe, he said, adding that transvaginal procedures are best performed in conjunction with a hysterectomy. One benefit of these procedures is that they avoid abdominal wall trauma. However, he cautioned that colorectal surgery is unique because a cancerous specimen cannot be morcellated and must instead be removed whole.
Dr. Mutch also discussed laparoendoscopic resection of colon polyps. Benefits include shorter length of stay and faster recovery, he said, but complications can include perforation and bleeding. And, he said, there’s currently no code for the procedure.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Mutch has no relevant disclosures.
LAS VEGAS – Two-thirds of colon resections in the United States are open procedures, but a colorectal surgeon told colleagues that evidence shows minimally invasive surgery deserves a wider place in his field.
Why? Because minimally invasive surgery – despite its limited utilization – is linked to multiple improved outcomes in colorectal surgery, said Matthew G. Mutch, MD, chief of colon and rectal surgery at Washington University, St. Louis, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“Our goal should be to offer minimally invasive surgery to as many patients as possible by as many different methods as needed,” Dr. Mutch said. “If you’re willing to take this on and do this over a regular basis, you’ll get over that learning curve and expand the number of patients you can offer laparoscopy to.”
According to Dr. Mutch, benefits of minimally invasive colorectal surgery include:
- Improved short-term outcomes – length of stay and return of bowel function, and morbidity and mortality. A 2012 retrospective study of 85,712 colon resections that found laparoscopic resections, when feasible, “had better outcomes than open colectomy in the immediate perioperative period.” (Ann Surg. 2012 Sep;256[3]462-8).
- Improved long-term outcomes: faster recovery, fewer hernias, and fewer bowel obstructions.
- Lower overall costs.
- Fewer complications in the elderly.
When it comes to laparoscopic colorectal surgery, Dr. Mutch cautioned that the robotic technology has unclear benefit in rectal cancer, and the cost in colorectal cancer is unclear.
Another alternative is to perform laparoscopic colorectal surgery through alternative extraction sites such as the rectum, vagina, stomach, and even a stoma site or perineal wound. Both transanal and transvaginal extraction are feasible and safe, he said, adding that transvaginal procedures are best performed in conjunction with a hysterectomy. One benefit of these procedures is that they avoid abdominal wall trauma. However, he cautioned that colorectal surgery is unique because a cancerous specimen cannot be morcellated and must instead be removed whole.
Dr. Mutch also discussed laparoendoscopic resection of colon polyps. Benefits include shorter length of stay and faster recovery, he said, but complications can include perforation and bleeding. And, he said, there’s currently no code for the procedure.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Mutch has no relevant disclosures.
LAS VEGAS – Two-thirds of colon resections in the United States are open procedures, but a colorectal surgeon told colleagues that evidence shows minimally invasive surgery deserves a wider place in his field.
Why? Because minimally invasive surgery – despite its limited utilization – is linked to multiple improved outcomes in colorectal surgery, said Matthew G. Mutch, MD, chief of colon and rectal surgery at Washington University, St. Louis, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“Our goal should be to offer minimally invasive surgery to as many patients as possible by as many different methods as needed,” Dr. Mutch said. “If you’re willing to take this on and do this over a regular basis, you’ll get over that learning curve and expand the number of patients you can offer laparoscopy to.”
According to Dr. Mutch, benefits of minimally invasive colorectal surgery include:
- Improved short-term outcomes – length of stay and return of bowel function, and morbidity and mortality. A 2012 retrospective study of 85,712 colon resections that found laparoscopic resections, when feasible, “had better outcomes than open colectomy in the immediate perioperative period.” (Ann Surg. 2012 Sep;256[3]462-8).
- Improved long-term outcomes: faster recovery, fewer hernias, and fewer bowel obstructions.
- Lower overall costs.
- Fewer complications in the elderly.
When it comes to laparoscopic colorectal surgery, Dr. Mutch cautioned that the robotic technology has unclear benefit in rectal cancer, and the cost in colorectal cancer is unclear.
Another alternative is to perform laparoscopic colorectal surgery through alternative extraction sites such as the rectum, vagina, stomach, and even a stoma site or perineal wound. Both transanal and transvaginal extraction are feasible and safe, he said, adding that transvaginal procedures are best performed in conjunction with a hysterectomy. One benefit of these procedures is that they avoid abdominal wall trauma. However, he cautioned that colorectal surgery is unique because a cancerous specimen cannot be morcellated and must instead be removed whole.
Dr. Mutch also discussed laparoendoscopic resection of colon polyps. Benefits include shorter length of stay and faster recovery, he said, but complications can include perforation and bleeding. And, he said, there’s currently no code for the procedure.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Mutch has no relevant disclosures.
EXPERT ANALYSIS FROM MISS
Bariatric surgery may be appropriate for class 1 obesity
LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m2.
In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”
As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m2) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, and chronic back pain.
“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”
There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.
Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”
In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m2. But this standard has evolved in recent years.
In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.
“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”
The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.
Bariatric surgery in the class 1 population does more than reduce obesity, Dr. Brethauer said. “Over the last 5 years or so, a large body of literature has emerged,” he said, and both systematic reviews and randomized trails have shown significant postsurgery improvements in comorbidities such as diabetes.
“It’s important to emphasize that these patients don’t become underweight,” he said. “The body finds a healthy set point. They don’t become underweight or malnourished because you’re operating on a lower-weight group.”
Are weight-loss operations safe in class 1 patients? The American Society for Metabolic and Bariatric Surgery statement says that research has found “bariatric surgery is associated with modest morbidity and very low mortality in patients with class I obesity.”
In fact, Dr. Brethauer said, the mortality rate in this population is “less than gallbladder surgery, less than hip surgery, less than hysterectomy, less than knee surgery – operations people are being referred for and undergoing all the time.”
He added: “The case can be made very clearly based on this data that these operations are safe in this patient population. Not only are they safe, they have durable and significant impact on comorbidities.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Brethauer discloses relationships with Medtronic (speaker) and GI Windows (consultant).
Review the AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper, which provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/WV8l30oeyYv.
LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m2.
In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”
As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m2) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, and chronic back pain.
“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”
There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.
Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”
In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m2. But this standard has evolved in recent years.
In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.
“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”
The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.
Bariatric surgery in the class 1 population does more than reduce obesity, Dr. Brethauer said. “Over the last 5 years or so, a large body of literature has emerged,” he said, and both systematic reviews and randomized trails have shown significant postsurgery improvements in comorbidities such as diabetes.
“It’s important to emphasize that these patients don’t become underweight,” he said. “The body finds a healthy set point. They don’t become underweight or malnourished because you’re operating on a lower-weight group.”
Are weight-loss operations safe in class 1 patients? The American Society for Metabolic and Bariatric Surgery statement says that research has found “bariatric surgery is associated with modest morbidity and very low mortality in patients with class I obesity.”
In fact, Dr. Brethauer said, the mortality rate in this population is “less than gallbladder surgery, less than hip surgery, less than hysterectomy, less than knee surgery – operations people are being referred for and undergoing all the time.”
He added: “The case can be made very clearly based on this data that these operations are safe in this patient population. Not only are they safe, they have durable and significant impact on comorbidities.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Brethauer discloses relationships with Medtronic (speaker) and GI Windows (consultant).
Review the AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper, which provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/WV8l30oeyYv.
LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m2.
In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”
As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m2) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, and chronic back pain.
“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”
There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.
Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”
In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m2. But this standard has evolved in recent years.
In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.
“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”
The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.
Bariatric surgery in the class 1 population does more than reduce obesity, Dr. Brethauer said. “Over the last 5 years or so, a large body of literature has emerged,” he said, and both systematic reviews and randomized trails have shown significant postsurgery improvements in comorbidities such as diabetes.
“It’s important to emphasize that these patients don’t become underweight,” he said. “The body finds a healthy set point. They don’t become underweight or malnourished because you’re operating on a lower-weight group.”
Are weight-loss operations safe in class 1 patients? The American Society for Metabolic and Bariatric Surgery statement says that research has found “bariatric surgery is associated with modest morbidity and very low mortality in patients with class I obesity.”
In fact, Dr. Brethauer said, the mortality rate in this population is “less than gallbladder surgery, less than hip surgery, less than hysterectomy, less than knee surgery – operations people are being referred for and undergoing all the time.”
He added: “The case can be made very clearly based on this data that these operations are safe in this patient population. Not only are they safe, they have durable and significant impact on comorbidities.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Brethauer discloses relationships with Medtronic (speaker) and GI Windows (consultant).
Review the AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper, which provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/WV8l30oeyYv.
REPORTING FROM MISS
Better communication with pharmacists can improve postop pain control
LAS VEGAS – . Watch out for overlapping medication orders. Beware of gabapentin mishaps, and embrace Tylenol – but not always.
April Smith, PharmD, associate professor of pharmacy practice at Creighton University, Omaha, offered these tips about postoperative care to surgeons at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We’re probably one of the most underutilized professions you have on your team,” she said, adding that “we have to know what you’re doing to help you.”
As she explained, “if you’re going to have a new order set, let us know that, so we can be your allies in helping nurses and other people understand why we’re doing what we’re doing. I’m on the same floor, and the nurses are coming up to me and asking me questions. If I can explain to them why we’re doing these things, they’ll get on board a lot faster and save you a lot of phone calls. I know you’re surgeons and you hate that [phone calls].”
Better communication with pharmacists can also boost the stocking of enhanced-recovery medications in automatic dispensing machines, she said, so they’re ready when patients need them.
Dr. Smith offered these tips about specific postsurgery medications:
- Scopolamine is a “great drug for post-op vomiting and nausea,” Dr. Smith said. But do not use it in patients over 65, and it’s contraindicated in glaucoma. Beware of these notable side effects: Blurry vision, constipation, and urinary retention. Dexamethasone and ondansetron can be used as an alternative, she said.
- Use of the blood thinner enoxaparin after discharge may become more common as surgical stays become shorter, Dr. Smith said. She urged surgeons to keep its cost in mind: a 10-day course can be as little as $2 with Medicaid or as much as $140 (a cash price for patients without coverage).
- Make sure to adjust medications based on preoperative or intraoperative doses, she said, to avoid endangering patients by inadvertently doubling up on doses. And watch out for previous use of gabapentin, which is part of enhanced-recovery protocols. Patients who take the drug at home should be put back on their typical dose.
- Also, she warned, “don’t give gabapentin to someone who’s never had it before plus an opioid.” This, she said, can cause delirium.
- Consider starting liquids the night of surgery so patients can begin taking their home medications such as sleep, chronic pain, and psychiatric drugs. Patients will be more stable and satisfied, Dr. Smith said.
- Don’t prescribe hard-to-find medications like oxycodone oral solution or oral ketorolac. These drugs will send patients from pharmacy to pharmacy in search of them, Dr. Smith said.
- Embrace a “Meds to Beds” program if possible. These programs enlist on-site pharmacies to deliver medications to bedside for patients to take home.
- Consider Tylenol as a postoperative painkiller with scheduled doses and be aware that you can prescribe the over-the-counter adult liquid form. However, Dr. Smith cautioned that Tylenol is “not great” on an as-needed basis. Gabapentin and celecoxib (unless contraindicated) are also helpful for postop pain relief, and they’re inexpensive, she said. Three to five days should be enough in most minimally invasive surgeries.
- Don’t overprescribe opioids. “The more we prescribe, the more they will consume,” Dr. Smith said. Check the American College of Surgeons guidelines regarding the ideal number of postsurgery, 5-mg doses of oxycodone to prescribe to opioid-naive patients at discharge. No more than 10 or 15 pills are recommended for several types of general surgery (J Amer Coll Surg. 2018;227:411-8).
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Smith reports no relevant disclosures.
LAS VEGAS – . Watch out for overlapping medication orders. Beware of gabapentin mishaps, and embrace Tylenol – but not always.
April Smith, PharmD, associate professor of pharmacy practice at Creighton University, Omaha, offered these tips about postoperative care to surgeons at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We’re probably one of the most underutilized professions you have on your team,” she said, adding that “we have to know what you’re doing to help you.”
As she explained, “if you’re going to have a new order set, let us know that, so we can be your allies in helping nurses and other people understand why we’re doing what we’re doing. I’m on the same floor, and the nurses are coming up to me and asking me questions. If I can explain to them why we’re doing these things, they’ll get on board a lot faster and save you a lot of phone calls. I know you’re surgeons and you hate that [phone calls].”
Better communication with pharmacists can also boost the stocking of enhanced-recovery medications in automatic dispensing machines, she said, so they’re ready when patients need them.
Dr. Smith offered these tips about specific postsurgery medications:
- Scopolamine is a “great drug for post-op vomiting and nausea,” Dr. Smith said. But do not use it in patients over 65, and it’s contraindicated in glaucoma. Beware of these notable side effects: Blurry vision, constipation, and urinary retention. Dexamethasone and ondansetron can be used as an alternative, she said.
- Use of the blood thinner enoxaparin after discharge may become more common as surgical stays become shorter, Dr. Smith said. She urged surgeons to keep its cost in mind: a 10-day course can be as little as $2 with Medicaid or as much as $140 (a cash price for patients without coverage).
- Make sure to adjust medications based on preoperative or intraoperative doses, she said, to avoid endangering patients by inadvertently doubling up on doses. And watch out for previous use of gabapentin, which is part of enhanced-recovery protocols. Patients who take the drug at home should be put back on their typical dose.
- Also, she warned, “don’t give gabapentin to someone who’s never had it before plus an opioid.” This, she said, can cause delirium.
- Consider starting liquids the night of surgery so patients can begin taking their home medications such as sleep, chronic pain, and psychiatric drugs. Patients will be more stable and satisfied, Dr. Smith said.
- Don’t prescribe hard-to-find medications like oxycodone oral solution or oral ketorolac. These drugs will send patients from pharmacy to pharmacy in search of them, Dr. Smith said.
- Embrace a “Meds to Beds” program if possible. These programs enlist on-site pharmacies to deliver medications to bedside for patients to take home.
- Consider Tylenol as a postoperative painkiller with scheduled doses and be aware that you can prescribe the over-the-counter adult liquid form. However, Dr. Smith cautioned that Tylenol is “not great” on an as-needed basis. Gabapentin and celecoxib (unless contraindicated) are also helpful for postop pain relief, and they’re inexpensive, she said. Three to five days should be enough in most minimally invasive surgeries.
- Don’t overprescribe opioids. “The more we prescribe, the more they will consume,” Dr. Smith said. Check the American College of Surgeons guidelines regarding the ideal number of postsurgery, 5-mg doses of oxycodone to prescribe to opioid-naive patients at discharge. No more than 10 or 15 pills are recommended for several types of general surgery (J Amer Coll Surg. 2018;227:411-8).
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Smith reports no relevant disclosures.
LAS VEGAS – . Watch out for overlapping medication orders. Beware of gabapentin mishaps, and embrace Tylenol – but not always.
April Smith, PharmD, associate professor of pharmacy practice at Creighton University, Omaha, offered these tips about postoperative care to surgeons at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We’re probably one of the most underutilized professions you have on your team,” she said, adding that “we have to know what you’re doing to help you.”
As she explained, “if you’re going to have a new order set, let us know that, so we can be your allies in helping nurses and other people understand why we’re doing what we’re doing. I’m on the same floor, and the nurses are coming up to me and asking me questions. If I can explain to them why we’re doing these things, they’ll get on board a lot faster and save you a lot of phone calls. I know you’re surgeons and you hate that [phone calls].”
Better communication with pharmacists can also boost the stocking of enhanced-recovery medications in automatic dispensing machines, she said, so they’re ready when patients need them.
Dr. Smith offered these tips about specific postsurgery medications:
- Scopolamine is a “great drug for post-op vomiting and nausea,” Dr. Smith said. But do not use it in patients over 65, and it’s contraindicated in glaucoma. Beware of these notable side effects: Blurry vision, constipation, and urinary retention. Dexamethasone and ondansetron can be used as an alternative, she said.
- Use of the blood thinner enoxaparin after discharge may become more common as surgical stays become shorter, Dr. Smith said. She urged surgeons to keep its cost in mind: a 10-day course can be as little as $2 with Medicaid or as much as $140 (a cash price for patients without coverage).
- Make sure to adjust medications based on preoperative or intraoperative doses, she said, to avoid endangering patients by inadvertently doubling up on doses. And watch out for previous use of gabapentin, which is part of enhanced-recovery protocols. Patients who take the drug at home should be put back on their typical dose.
- Also, she warned, “don’t give gabapentin to someone who’s never had it before plus an opioid.” This, she said, can cause delirium.
- Consider starting liquids the night of surgery so patients can begin taking their home medications such as sleep, chronic pain, and psychiatric drugs. Patients will be more stable and satisfied, Dr. Smith said.
- Don’t prescribe hard-to-find medications like oxycodone oral solution or oral ketorolac. These drugs will send patients from pharmacy to pharmacy in search of them, Dr. Smith said.
- Embrace a “Meds to Beds” program if possible. These programs enlist on-site pharmacies to deliver medications to bedside for patients to take home.
- Consider Tylenol as a postoperative painkiller with scheduled doses and be aware that you can prescribe the over-the-counter adult liquid form. However, Dr. Smith cautioned that Tylenol is “not great” on an as-needed basis. Gabapentin and celecoxib (unless contraindicated) are also helpful for postop pain relief, and they’re inexpensive, she said. Three to five days should be enough in most minimally invasive surgeries.
- Don’t overprescribe opioids. “The more we prescribe, the more they will consume,” Dr. Smith said. Check the American College of Surgeons guidelines regarding the ideal number of postsurgery, 5-mg doses of oxycodone to prescribe to opioid-naive patients at discharge. No more than 10 or 15 pills are recommended for several types of general surgery (J Amer Coll Surg. 2018;227:411-8).
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Smith reports no relevant disclosures.
EXPERT ANALYSIS FROM MISS
Bariatric surgery may be appropriate for class 1 obesity
LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m2.
In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”
As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m2) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, knee pain and chronic back pain.
“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”
There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.
Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”
In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m2. But this standard has evolved in recent years.
In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.
“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”
The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.
Bariatric surgery in the class 1 population does more than reduce obesity, Dr. Brethauer said. “Over the last 5 years or so, a large body of literature has emerged,” he said, and both systematic reviews and randomized trails have shown significant postsurgery improvements in comorbidities such as diabetes.
“It’s important to emphasize that these patients don’t become underweight,” he said. “The body finds a healthy set point. They don’t become underweight or malnourished because you’re operating on a lower-weight group.”
Are weight-loss operations safe in class 1 patients? The American Society for Metabolic and Bariatric Surgery statement says that research has found “bariatric surgery is associated with modest morbidity and very low mortality in patients with class I obesity.”
In fact, Dr. Brethauer said, the mortality rate in this population is “less than gallbladder surgery, less than hip surgery, less than hysterectomy, less than knee surgery – operations people are being referred for and undergoing all the time.”
He added: “The case can be made very clearly based on this data that these operations are safe in this patient population. Not only are they safe, they have durable and significant impact on comorbidities.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Brethauer discloses relationships with Medtronic (speaker) and GI Windows (consultant).
LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m2.
In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”
As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m2) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, knee pain and chronic back pain.
“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”
There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.
Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”
In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m2. But this standard has evolved in recent years.
In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.
“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”
The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.
Bariatric surgery in the class 1 population does more than reduce obesity, Dr. Brethauer said. “Over the last 5 years or so, a large body of literature has emerged,” he said, and both systematic reviews and randomized trails have shown significant postsurgery improvements in comorbidities such as diabetes.
“It’s important to emphasize that these patients don’t become underweight,” he said. “The body finds a healthy set point. They don’t become underweight or malnourished because you’re operating on a lower-weight group.”
Are weight-loss operations safe in class 1 patients? The American Society for Metabolic and Bariatric Surgery statement says that research has found “bariatric surgery is associated with modest morbidity and very low mortality in patients with class I obesity.”
In fact, Dr. Brethauer said, the mortality rate in this population is “less than gallbladder surgery, less than hip surgery, less than hysterectomy, less than knee surgery – operations people are being referred for and undergoing all the time.”
He added: “The case can be made very clearly based on this data that these operations are safe in this patient population. Not only are they safe, they have durable and significant impact on comorbidities.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Brethauer discloses relationships with Medtronic (speaker) and GI Windows (consultant).
LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m2.
In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”
As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m2) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, knee pain and chronic back pain.
“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”
There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.
Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”
In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m2. But this standard has evolved in recent years.
In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.
“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”
The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.
Bariatric surgery in the class 1 population does more than reduce obesity, Dr. Brethauer said. “Over the last 5 years or so, a large body of literature has emerged,” he said, and both systematic reviews and randomized trails have shown significant postsurgery improvements in comorbidities such as diabetes.
“It’s important to emphasize that these patients don’t become underweight,” he said. “The body finds a healthy set point. They don’t become underweight or malnourished because you’re operating on a lower-weight group.”
Are weight-loss operations safe in class 1 patients? The American Society for Metabolic and Bariatric Surgery statement says that research has found “bariatric surgery is associated with modest morbidity and very low mortality in patients with class I obesity.”
In fact, Dr. Brethauer said, the mortality rate in this population is “less than gallbladder surgery, less than hip surgery, less than hysterectomy, less than knee surgery – operations people are being referred for and undergoing all the time.”
He added: “The case can be made very clearly based on this data that these operations are safe in this patient population. Not only are they safe, they have durable and significant impact on comorbidities.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Brethauer discloses relationships with Medtronic (speaker) and GI Windows (consultant).
REPORTING FROM MISS
Robotic surgery offers minimally invasive approach to complex patients
LAS VEGAS – Colorectal surgeon Jamie Cannon, MD, doesn’t think there’s a rivalry between laparoscopic surgery and robotic surgery. Instead, she told colleagues, they should be seen as parts of the same whole: “Robotics is laparoscopy. It’s just a tool that allows us to do laparoscopic surgery better.”
Specifically, robotic surgery deserves a prominent place in treatment for rectal cancer, Dr. Cannon, associate professor of surgery at the University of Alabama at Birmingham, said in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We can reduce the conversion rate and offer more complex patients a minimally invasive operation,” she said.
Dr. Cannon listed these benefits of robotic surgery:
• Better cameras offer 3-D visualization.
• A stable operating platform provides tremor control.
• Instruments are fully articulated.
• The ability to perform fine dissection and complex suturing in confined spaces is enhanced.
• Ergonomics are improved.
“From a surgeon’s standpoint, it’s a lot more fun and a lot more comfortable,” she said. “You’re sitting there rather than straining your neck and arms to accomplish something difficult.”
Statistics show that robotics is gaining on open surgery in anterior rectal resection procedures while laparoscopy remains flat, she noted. In 2008, she said, the percentages for open, laparoscopic and robotic procedures were 81%, 18% and 1%, respectively. In 2015, they were 60%, 20% and 19%, respectively.
According to Dr. Cannon, other benefits of robotic surgery in rectal resections include better outcomes in difficult patients and lower conversion rates.
A 2017 prospective, randomized study did not show a difference between laparoscopic and robotic approaches to conversion rates in rectal resection, she noted (JAMA. 2017;318[16]:1569-80).
However, she said, a newer study presented at the Academic Surgical Congress in 2018 did show a major difference, with a conversion rate of 17% in laparoscopic procedures (n = 128) and 1% in robotic procedures (n = 92, P less than .05). Conversion rates in obese patients were similar.
In regard to obese patients, “we know they don’t do well,” Dr. Cannon said. “One thing we don’t always talk about is the impact on surgeons. These cases are very difficult to do.” Robotic technology allows surgeons to “make up for the challenges you experience laparoscopically” in these procedures, she said.
Robotics can be helpful because they allow surgeons to offer minimally invasive surgery to patients who pose challenges because of morbid obesity, inflammatory conditions such as Crohn’s disease and enteric fistulas, and histories of multiple previous surgeries, she added.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Cannon disclosed serving as an instructor for Intuitive Surgical.
LAS VEGAS – Colorectal surgeon Jamie Cannon, MD, doesn’t think there’s a rivalry between laparoscopic surgery and robotic surgery. Instead, she told colleagues, they should be seen as parts of the same whole: “Robotics is laparoscopy. It’s just a tool that allows us to do laparoscopic surgery better.”
Specifically, robotic surgery deserves a prominent place in treatment for rectal cancer, Dr. Cannon, associate professor of surgery at the University of Alabama at Birmingham, said in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We can reduce the conversion rate and offer more complex patients a minimally invasive operation,” she said.
Dr. Cannon listed these benefits of robotic surgery:
• Better cameras offer 3-D visualization.
• A stable operating platform provides tremor control.
• Instruments are fully articulated.
• The ability to perform fine dissection and complex suturing in confined spaces is enhanced.
• Ergonomics are improved.
“From a surgeon’s standpoint, it’s a lot more fun and a lot more comfortable,” she said. “You’re sitting there rather than straining your neck and arms to accomplish something difficult.”
Statistics show that robotics is gaining on open surgery in anterior rectal resection procedures while laparoscopy remains flat, she noted. In 2008, she said, the percentages for open, laparoscopic and robotic procedures were 81%, 18% and 1%, respectively. In 2015, they were 60%, 20% and 19%, respectively.
According to Dr. Cannon, other benefits of robotic surgery in rectal resections include better outcomes in difficult patients and lower conversion rates.
A 2017 prospective, randomized study did not show a difference between laparoscopic and robotic approaches to conversion rates in rectal resection, she noted (JAMA. 2017;318[16]:1569-80).
However, she said, a newer study presented at the Academic Surgical Congress in 2018 did show a major difference, with a conversion rate of 17% in laparoscopic procedures (n = 128) and 1% in robotic procedures (n = 92, P less than .05). Conversion rates in obese patients were similar.
In regard to obese patients, “we know they don’t do well,” Dr. Cannon said. “One thing we don’t always talk about is the impact on surgeons. These cases are very difficult to do.” Robotic technology allows surgeons to “make up for the challenges you experience laparoscopically” in these procedures, she said.
Robotics can be helpful because they allow surgeons to offer minimally invasive surgery to patients who pose challenges because of morbid obesity, inflammatory conditions such as Crohn’s disease and enteric fistulas, and histories of multiple previous surgeries, she added.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Cannon disclosed serving as an instructor for Intuitive Surgical.
LAS VEGAS – Colorectal surgeon Jamie Cannon, MD, doesn’t think there’s a rivalry between laparoscopic surgery and robotic surgery. Instead, she told colleagues, they should be seen as parts of the same whole: “Robotics is laparoscopy. It’s just a tool that allows us to do laparoscopic surgery better.”
Specifically, robotic surgery deserves a prominent place in treatment for rectal cancer, Dr. Cannon, associate professor of surgery at the University of Alabama at Birmingham, said in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We can reduce the conversion rate and offer more complex patients a minimally invasive operation,” she said.
Dr. Cannon listed these benefits of robotic surgery:
• Better cameras offer 3-D visualization.
• A stable operating platform provides tremor control.
• Instruments are fully articulated.
• The ability to perform fine dissection and complex suturing in confined spaces is enhanced.
• Ergonomics are improved.
“From a surgeon’s standpoint, it’s a lot more fun and a lot more comfortable,” she said. “You’re sitting there rather than straining your neck and arms to accomplish something difficult.”
Statistics show that robotics is gaining on open surgery in anterior rectal resection procedures while laparoscopy remains flat, she noted. In 2008, she said, the percentages for open, laparoscopic and robotic procedures were 81%, 18% and 1%, respectively. In 2015, they were 60%, 20% and 19%, respectively.
According to Dr. Cannon, other benefits of robotic surgery in rectal resections include better outcomes in difficult patients and lower conversion rates.
A 2017 prospective, randomized study did not show a difference between laparoscopic and robotic approaches to conversion rates in rectal resection, she noted (JAMA. 2017;318[16]:1569-80).
However, she said, a newer study presented at the Academic Surgical Congress in 2018 did show a major difference, with a conversion rate of 17% in laparoscopic procedures (n = 128) and 1% in robotic procedures (n = 92, P less than .05). Conversion rates in obese patients were similar.
In regard to obese patients, “we know they don’t do well,” Dr. Cannon said. “One thing we don’t always talk about is the impact on surgeons. These cases are very difficult to do.” Robotic technology allows surgeons to “make up for the challenges you experience laparoscopically” in these procedures, she said.
Robotics can be helpful because they allow surgeons to offer minimally invasive surgery to patients who pose challenges because of morbid obesity, inflammatory conditions such as Crohn’s disease and enteric fistulas, and histories of multiple previous surgeries, she added.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Cannon disclosed serving as an instructor for Intuitive Surgical.
REPORTING FROM MISS
Time to revisit fasting rules for surgery patients
LAS VEGAS – Anesthesiologist Michael W. Manning, MD, has a few unusual rules about preparing patients for surgery: Give them a carb-heavy beverage. Definitely provide caffeine to coffee addicts who haven’t had a cup for quite a while. And tell them – again and again – what to expect in terms of pain.
All of these strategies can boost recovery, Dr. Manning, assistant professor of anesthesiology at Duke University Medical Center, Durham, N.C., said in a pair of presentations at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Dr. Manning’s tips
Don’t starve patients before procedures: “We should prep for a surgery like a marathon,” Dr. Manning recommended. That means allowing patients to eat and drink instead of starving them via fasting out of fear that they’ll aspirate under anesthesia, he said.
He pointed to 2017 guidelines issued by the American Society of Anesthesiologists, indicating that patients may drink clear liquids for up to 2 hours before procedures that require general or regional anesthesia or procedural sedation and anesthesia. And patients may consume a light meal, such as toast and a clear liquid, or nonhuman milk, until 6 hours before a procedure. However, they should fast 8 hours after eating fried or fatty foods or meat (Anesthesiology 2017:376-93).
Extensive research supports carb-loading via liquid prior to surgery, said Dr. Manning, who cited a 2014 Cochrane Library review that examined 27 trials on preoperative consumption of carbs prior to various types of surgery. The review found no increase in complications in patients who consumed carbs, compared with placebo or fasting, and there was a slight decrease in length of stay (Cochrane Database Syst Rev. 2014 Aug 14;[8]).
In terms of benefits, research suggests that carb-loading improves patient comfort and gastric emptying, Dr. Manning said, and patients welcome it.
Educate patients about pain expectations
“We surgeons and anesthesiologists need to partner together and talk to patients and define what the pain expectations are,” Dr. Manning said.
At Duke, physicians worked together to set up a script that patients will hear four different times by medical personnel such as the surgeon, the anesthesiologist, and nursing staff, he said.
The script aims to educate patients about what to expect in terms of pain. For example, he says, before some surgeries, patients might be told: “You’re going to have shoulder pain that’s going to feel like you’ve been in the garage all day putting boxes on the shelf all the time,” or “Your belly is going to feel like you did 1,000 sit-ups.”
This eliminates the “fear and anxiety” that comes with not knowing what to expect regarding pain, he said.
Ask about coffee. Yes, coffee.
According to Dr. Manning, patients who regularly drink “a robust amount” of coffee may experience more postoperative pain following afternoon surgery because they’ve gone for an unusually long time without caffeine. Take a “coffee history,” he advised, and ask how much coffee the patient would have consumed by this time on a normal day. Then give patients caffeine as needed. (Coffee is considered a clear beverage under the American Society of Anesthesiologists guidelines.)
“It takes the edge off and helps reduce postoperative pain,” he said.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Manning has no disclosures.
LAS VEGAS – Anesthesiologist Michael W. Manning, MD, has a few unusual rules about preparing patients for surgery: Give them a carb-heavy beverage. Definitely provide caffeine to coffee addicts who haven’t had a cup for quite a while. And tell them – again and again – what to expect in terms of pain.
All of these strategies can boost recovery, Dr. Manning, assistant professor of anesthesiology at Duke University Medical Center, Durham, N.C., said in a pair of presentations at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Dr. Manning’s tips
Don’t starve patients before procedures: “We should prep for a surgery like a marathon,” Dr. Manning recommended. That means allowing patients to eat and drink instead of starving them via fasting out of fear that they’ll aspirate under anesthesia, he said.
He pointed to 2017 guidelines issued by the American Society of Anesthesiologists, indicating that patients may drink clear liquids for up to 2 hours before procedures that require general or regional anesthesia or procedural sedation and anesthesia. And patients may consume a light meal, such as toast and a clear liquid, or nonhuman milk, until 6 hours before a procedure. However, they should fast 8 hours after eating fried or fatty foods or meat (Anesthesiology 2017:376-93).
Extensive research supports carb-loading via liquid prior to surgery, said Dr. Manning, who cited a 2014 Cochrane Library review that examined 27 trials on preoperative consumption of carbs prior to various types of surgery. The review found no increase in complications in patients who consumed carbs, compared with placebo or fasting, and there was a slight decrease in length of stay (Cochrane Database Syst Rev. 2014 Aug 14;[8]).
In terms of benefits, research suggests that carb-loading improves patient comfort and gastric emptying, Dr. Manning said, and patients welcome it.
Educate patients about pain expectations
“We surgeons and anesthesiologists need to partner together and talk to patients and define what the pain expectations are,” Dr. Manning said.
At Duke, physicians worked together to set up a script that patients will hear four different times by medical personnel such as the surgeon, the anesthesiologist, and nursing staff, he said.
The script aims to educate patients about what to expect in terms of pain. For example, he says, before some surgeries, patients might be told: “You’re going to have shoulder pain that’s going to feel like you’ve been in the garage all day putting boxes on the shelf all the time,” or “Your belly is going to feel like you did 1,000 sit-ups.”
This eliminates the “fear and anxiety” that comes with not knowing what to expect regarding pain, he said.
Ask about coffee. Yes, coffee.
According to Dr. Manning, patients who regularly drink “a robust amount” of coffee may experience more postoperative pain following afternoon surgery because they’ve gone for an unusually long time without caffeine. Take a “coffee history,” he advised, and ask how much coffee the patient would have consumed by this time on a normal day. Then give patients caffeine as needed. (Coffee is considered a clear beverage under the American Society of Anesthesiologists guidelines.)
“It takes the edge off and helps reduce postoperative pain,” he said.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Manning has no disclosures.
LAS VEGAS – Anesthesiologist Michael W. Manning, MD, has a few unusual rules about preparing patients for surgery: Give them a carb-heavy beverage. Definitely provide caffeine to coffee addicts who haven’t had a cup for quite a while. And tell them – again and again – what to expect in terms of pain.
All of these strategies can boost recovery, Dr. Manning, assistant professor of anesthesiology at Duke University Medical Center, Durham, N.C., said in a pair of presentations at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
Dr. Manning’s tips
Don’t starve patients before procedures: “We should prep for a surgery like a marathon,” Dr. Manning recommended. That means allowing patients to eat and drink instead of starving them via fasting out of fear that they’ll aspirate under anesthesia, he said.
He pointed to 2017 guidelines issued by the American Society of Anesthesiologists, indicating that patients may drink clear liquids for up to 2 hours before procedures that require general or regional anesthesia or procedural sedation and anesthesia. And patients may consume a light meal, such as toast and a clear liquid, or nonhuman milk, until 6 hours before a procedure. However, they should fast 8 hours after eating fried or fatty foods or meat (Anesthesiology 2017:376-93).
Extensive research supports carb-loading via liquid prior to surgery, said Dr. Manning, who cited a 2014 Cochrane Library review that examined 27 trials on preoperative consumption of carbs prior to various types of surgery. The review found no increase in complications in patients who consumed carbs, compared with placebo or fasting, and there was a slight decrease in length of stay (Cochrane Database Syst Rev. 2014 Aug 14;[8]).
In terms of benefits, research suggests that carb-loading improves patient comfort and gastric emptying, Dr. Manning said, and patients welcome it.
Educate patients about pain expectations
“We surgeons and anesthesiologists need to partner together and talk to patients and define what the pain expectations are,” Dr. Manning said.
At Duke, physicians worked together to set up a script that patients will hear four different times by medical personnel such as the surgeon, the anesthesiologist, and nursing staff, he said.
The script aims to educate patients about what to expect in terms of pain. For example, he says, before some surgeries, patients might be told: “You’re going to have shoulder pain that’s going to feel like you’ve been in the garage all day putting boxes on the shelf all the time,” or “Your belly is going to feel like you did 1,000 sit-ups.”
This eliminates the “fear and anxiety” that comes with not knowing what to expect regarding pain, he said.
Ask about coffee. Yes, coffee.
According to Dr. Manning, patients who regularly drink “a robust amount” of coffee may experience more postoperative pain following afternoon surgery because they’ve gone for an unusually long time without caffeine. Take a “coffee history,” he advised, and ask how much coffee the patient would have consumed by this time on a normal day. Then give patients caffeine as needed. (Coffee is considered a clear beverage under the American Society of Anesthesiologists guidelines.)
“It takes the edge off and helps reduce postoperative pain,” he said.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Manning has no disclosures.
REPORTING FROM MISS
Anti-mesh trend may be felt by surgeons doing hernia repairs
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
REPORTING FROM MISS
Stop-smoking rule before hernia repairs: Time for a rethink?
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
REPORTING FROM MISS
Evidence weak for robotic inguinal hernia surgery
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM MISS