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  1. 1. WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor August 2008 THE BEST THIS MONTH’S UPDATES SURGICAL Elements of Contemporary from that in other developed countries is the market-based THINKING Practice 8 Health Care Economics: delivery system that characterizes U.S. health care. Because more than 45 million U.S. Hand-Assisted Laparoscopic The Broader Context citizens (almost one out of six) Colectomy: A Bridge to cannot afford health insurance LINDA G. LESKY, MD, MA, coverage, the costs of this care are Increased Minimal Access built into the prices charged to those Colectomies Associate Professor of Medicine and who do have the ability to pay. Health Policy, George Washington ROBERT R. CIMA, MD, MA, FACS, Despite this degree of public University, Washington, DC FASCRS spending, the uninsured have poorer Assistant Professor of Surgery, ROBERT S. RHODES, MD, FACS health outcomes than those with Mayo Clinic College of Medicine, Adjunct Professor, Department of continuous health insurance Division of Colon and Rectal Surgery, University of Pennsylvania coverage. Surgery, Mayo Clinic, Rochester, School of Medicine, Philadelphia, Substantial evidence exists to MN PA support the notion that physicians increase the demand for health care. JOHN H. PEMBERTON, MD, FACS CHARLES L. RICE, MD, FACS Professor of Surgery, Mayo Clinic Because of this asymmetric knowl- College of Medicine, Division of President, Professor of Surgery, edge, consumers rely heavily on Colon and Rectal Surgery, Mayo Uniformed Services University of the physician advice for guidance Clinic, Rochester, MN Health Sciences, Bethesda, MD regarding diagnosis and treatment. Thus, not only do physicians DOI 10.2310/7800.2008.NCaug DOI 10.2310/7800.SECC08 function as suppliers of health care aparoscopic colectomy (LC) services, but they also play a major L confers numerous short-term patient benefits.1 These benefits Surgeons should have a broad understanding of health-care role in determining the level of demand for these services. spending. include fewer infectious complica- continued on page 3 n 2006, U.S. National Health tions, less pain, fewer pulmonary complications, decreased need for I Expenditures amounted to $2.1 blood transfusions, and shorter hospital stays. Furthermore, it has trillion, translating into a per capita expenditure of $7,026. Projections In This Issue been shown in several randomized indicate that total health care The Best Surgical Thinking controlled trials that LC for spending will reach $4 trillion by Hand-Assisted Laparoscopic colorectal cancer achieves short- and 2015, and double again by 2035. Colectomy: A Bridge to Increased long-term oncologic outcomes The majority is projected to be Minimal Access Colectomies 1 equivalent to those of conventional attributable to rising costs of care. Elements of Contemporary Practice surgery.2,3 Although it has been over 8 Health Care Economics: The 15 years since the first reported LC, Broader Context 1 LC is performed in only about 6% Discrepancy between 1 Basic Surgical and Perioperative of patients currently undergoing Health Care Costs and Considerations 9 Fast Track Inpatient and Ambulatory colectomy in this country.4 This rate Outcomes Surgery 4 of adoption for LC is much slower he single factor that distinguishes 8 Critical Care continued on page 2 T health care in the United States 22 Nutritional Support 4
  2. 2. 2 What’s New in ACS Surgery • August 2008 THE BEST SURGICAL THINKING continued from page 1 Owned and published by than for other general surgical BC Decker Inc special access device (Figure 1) abdominal procedures, such as that is placed through the EDITORIAL CHAIR: Wiley W. Souba, MD, SCD, FACS, Columbus, OH cholecystectomy, hernia repair, abdominal wall that allows a gastroesophageal reflux surgery, pneumoperitoneum to be established FOUNDING EDITOR: Douglas W. Wilmore, MD, FACS, Boston and gastric banding or bypass and maintained while permitting the EDITORIAL BOARD: procedures, despite a much larger surgeon to place a hand in the Mitchell P. Fink, md, facs, Pittsburgh Gregory volume of literature supporting the abdomen to assist in laparoscopic J. Jurkovich, md, facs, Seattle Larry R. Kaiser, md, facs, Philadelphia William H. Pearce, md, feasibility and safety of LC. retraction, dissection, and visualiza- facs, Chicago John H. Pemberton, md, facs, The most likely reason for the tion. This technique has been Rochester, MN Nathaniel J. Soper, md, facs, slow adoption of LC is that it is successfully used for a wide variety Chicago technically much more complex of general, urologic, and gynecologic COUNCIL OF FOUNDING EDITORS: Murray F. Brennan, md, facs, New York than other procedures because the procedures, as well as colectomy.5 Laurence Y. Cheung, md, facs, Kansas City organ of interest is large and mobile, The use of HALS for colectomy Alden H. Harken, md, facs, San Francisco dissection must be performed in has been shown to result in clinical James W. Holcroft, md, facs, Sacramento Jonathan L. Meakins, md, dsc, facs, Oxford multiple quadrants of the abdomen, outcomes similar to those of LC but PUBLISHER: and there are numerous large vessels is associated with a much lower rate President, Brian C. Decker that require division. Furthermore, of conversion to an open procedure Vice President, Sales, Rochelle J. Decker LC is associated with longer because of technical problems or Vice President and Publisher, Liz Pope Managing Editor, Susan Cooper operative times compared to intraoperative complications and Manager, Special Sales, Jennifer Coates the traditional open procedure. has a significantly shorter operative Manager, Customer Care and Distribution, Marie Moore Although many of these problems time.6–9 Also, it has been reported Rights and Permissions, Paula Mucci are overcome with experience, the that HALS has decreased the Director, Digital Publishing, David Love learning curve is estimated for learning curve for the surgeon with Electronic Media Systems Analyst, Jeff Ferguson Senior Web/IT Developer, Faisal Shah routine LC at somewhere between no experience performing LC and ACS Surgery: Principles & Practice (bound 20 and 50 cases. This number is expanded the complexity of minimal volume: ISBN 978-1-55009-399-5; CD-ROM: higher than the average number of access colorectal procedures the ISBN 978-1-55009-421-3; quarterly CD ROM: colectomies performed per year by surgeon can offer.6 These benefits of ISSN 1538-3210; online: ISSN 1547-1616) is owned and published by BC Decker Inc, 50 King most community-based general HALS are thought to be related to St. E., 2nd Floor, PO Box 620, LCD1, Hamilton, surgeons. increased “efficiency” of the ON L8N 3K7, Canada, Web site: http://www. © 2008 BC Decker Inc. All rights A hybrid technique, hand-assisted operation compared with traditional reserved. No part of this issue may be reproduced laparoscopic surgery (HALS), LC; comparative video analysis of by any mechanical, photographic, or electronic process or in the form of a phonographic represents a technology that HALS and LC showed that HALS recording, nor may it be stored in a retrieval provides many of the advantages of colectomies were associated with system, transmitted, or otherwise copied for traditional open surgery while significantly more “goal-oriented” public or private use without written permission of the publisher. maintaining the short-term clinical behavior than the traditional benefits of LC. HALS employs a Annual subscription rates in Canada and the laparoscopic technique. In a USA: Quarterly CD-ROM: $209 (individual), $709 (institutional); Online: $189 (individual). Institutional Web site license pricing available on request. Please e-mail Separate shipping and handling apply. All prices subject to change without notice and quoted in US dollars. POSTMASTER: Send address changes to BC Decker Inc, PO Box 758, Lewiston, NY 14092- 0785. FOR ASSISTANCE WITH YOUR SUBSCRIPTION Please address all inquiries to Fulfillment Department, BC Decker Inc, P.O. Box 758, Lewiston, NY 14092- 0785, or call us at 905-522-7017 or 800-568-7281, or fax us at 905-522-7839 or 888-311-4987, or email us at For change of address, please provide both your new and your old addresses; be sure to notify us at least six weeks before you expect to move to avoid interruptions in your service. YOUR FEEDBACK IS WELCOME • E-mail: • Write: BC Decker Inc P.O. Box 620, LCD1 Hamilton, ON L8N 3K7 Canada Figure 1. A hand access device permits the surgeon to place a hand in the abdomen and still use laparoscopic visualization and instrumentation through standard trocars. The typical incision is 7 to 7.5 cm in length. continued on page 3
  3. 3. What’s New in ACS Surgery 3 THE BEST SURGICAL THINKING This Month’s CME continued from page 2 Chapters prospective trial comparing HALS colorectal resection outcomes: ACS Surgery offers CME in colectomy and LC, the HALS short-term comparison with open convenient online format. As approach had a far lower conversion procedures. J Am Coll Surg many as 60 AMA PRA Category rate, 7% compared with 23%, while 2007;204:291–307. 1 credits can be earned at any time during the year. The preserving the same immediate 2. Janson M, Björholt I, Carlsson following chapters are available clinical outcomes.7 P, et al. Randomized clinical trial for CME credit this month: In a recent report from Mayo of the costs of open and laparo- Clinic, an analysis of 969 minimally scopic surgery for colonic cancer. Elements of Contemporary Practice invasive colectomies was performed Br J Surg 2004;91:409–17. 8 Health Care Economics: The Broader over a 3-year period during which 3. Clinical Outcomes of Surgical Context HALS colectomies were first Therapy Study Group: a compari- 1 Basic Surgical and Perioperative introduced into the practice.8 The Considerations son of laparoscopically assisted 9 Fast Track Inpatient and Ambulatory authors found that at the end of the and open colectomy for colon Surgery study period, HALS had accounted cancer. N Engl J Med 2004;350: for 373 of the colectomies. Although 8 Critical Care 2050–9. 22 Nutritional Support HALS was used for all types of 4. Kemp JA, Finlayson SRG. Nation- colectomies, from segmental to total wide trends in laparoscopic proctocolectomies and ileal pouch colectomy from 2000-2004. Surg procedures, it was preferentially used for left-sided and total colecto- mies. In particular, HALS became 5. Endosc 2008 (Feb 1);1181–7. Maarense S, Bemelman W, van der Hoop G, et al. Hand-assisted THIS MONTH’S the primary modality for minimally invasive total proctocolectomy with ileal pouch anal anastomosis. laparoscopic surgery (HALS): a report of 150 procedures. Surg Endosc 2004;18:397–401. UPDATES continued from page 1 Furthermore, HALS retained nearly all of the short-term clinical benefits 6. Cima RR, Hassan I, Larson DW, et al. Impact of a new technology, In virtually every other sector of of traditional LC but was associated the economy, the introduction of with significantly shorter operative hand-assisted laparoscopic sur- gery (HALS) in a specialty colo- new technology tends to reduce the times and conversions to open cost of a particular good or service. surgery compared with LC. rectal surgical practice at a single institution (abstract P 155). Pre- Health care is an exception. A 2003 Minimally invasive procedures sented at the Society of American analysis of the relation between the provide numerous clinical advan- Gastrointestinal and Endoscopic availability of advanced technologies tages for patients. After LC, patients Surgeons Scientific Sessions; 2006 and health care spending found that experience less pain, have fewer April 26–29; Dallas, TX. for certain technologies (e.g., postoperative complications, require fewer blood transfusions, and have 7. Targarona E, Gracia E, Garriga J, diagnostic imaging, cardiac catheter- shorter hospital stays. However, et al. Prospective randomized trial ization facilities, and intensive care traditional LC is technically de- comparing conventional laparo- facilities), increased availability was manding and requires extensive scopic colectomy with hand- often accompanied by increased training to master. HALS colectomy assisted laparoscopic colectomy: usage (and thus increased spending). is a unique minimally invasive applicability, immediate clinical In general economic terms, modality that bridges the gap outcome, inflammatory response, markets function best and society between traditional open colectomy benefits most when multiple and cost. Surg Endosc 2002;16: and LC. HALS provides the same suppliers compete to produce the 234–9. clinical benefits as LC but is less highest quality product at the lowest 8. Cima RR, Pattana-arun J, Larson technically demanding and is cost. With health care, however, this DW, et al. Experience with 969 performed more quickly. This process has resulted in a bewildering minimal access colectomies: the technique could easily expand the array of insurers and contracts. role of hand assisted laparoscopy number of patients in the United Virtually every physician in the (HALS) in expanding minimally States undergoing colectomy who United States has had to expend invasive surgery for complex could benefit from a minimal access considerable time and effort dealing colectomies. J Am Coll Surg 2008; surgical approach. with complicated, arcane, and 206:946–50; discussion 950–2. confusing administrative costs and 9. Meijer D, Bannenberg J, Jakimo- References requirements. wicz J. Hand-assisted laparo- 1. Noel JK, Fahrbach K, Estok scopic surgery: an overview. Surg R, et al. Minimally invasive Endosc 2000;14:891–5. continued on page 4
  4. 4. 4 What’s New in ACS Surgery • August 2008 THIS MONTH’S UPDATES continued from page 3 Health Care Economics and patients with moderate and severe common reason for delaying preoperative undernutrition benefit discharge after ambulatory surgery. Implications for Surgeons from preoperative nutritional Due to the important side effects of lthough individual physicians A cannot fix the society-wide problems created by market-based support. Also, improving functional capacity by increasing physical activity before surgery may be opioids, it is more sensible to consider multimodal analgesia. Regarding postoperative feeding, health care, surgeons can help to protective. In another area, several studies suggest that early restore confidence in the profession emerging evidence suggests that it feeding (not waiting until peristalsis by helping develop and then may be beneficial to forgo absolute has returned to the entire GI tract) adhering to evidence-based preoperative fasting, providing a offers decreased overall infectious approaches to surgical intervention. carbohydrate drink the evening complications and reduced length of Communication skills and attention before surgery and a second drink to the needs of patients should be stay. Postoperative bed rest should 2 to 3 hours before induction of stressed as vital to the best patient anesthesia. Results from meta- be discouraged, and patients should care. analyses suggest that preoperative be educated on the benefits of early patient education and preparation mobilization. Also, because drains have positive effects on certain and catheters impede independent 1 Basic Surgical and Perioperative outcomes like pain and psychologi- ambulation, their routine use should cal distress. Finally, premedication be weighed carefully. Finally, Considerations may modulate intraoperative because of the earlier hospital hemodynamics and reduce discharge with fast track programs, 9 Fast Track Inpatient and postoperative side effects. discharge follow-up is important, Ambulatory Surgery Intraoperative elements are also with patients able to contact a team vital. To attenuate the surgical stress member easily should problems LIANE FELDMAN, MD, FACS, FRCS response, epidural and spinal block arise. using local anesthetics have been Associate Professor of Surgery, shown to be the most powerful McGill University, Montreal, QC, modulator of the metabolic and Implementation of a Fast Canada Track Surgery Program endocrine stress response. Regarding FRANCO CARLI, MD, PHD, FRCA, general anesthesia, any choice mplementing a fast track surgery FRCPC should include fast-acting IV drugs and less soluble volatile anesthetics, I program and multimodal rehabili- tation requires substantial resources Professor, Department of along with adjuvants to minimize Anesthesia, McGill University, and effort. Additionally, more side effects. For regional anesthesia, research is required to understand Montreal, QC, Canada spinal, epidural, and peripheral which of the multiple individual DOI 10.2310/7800.S01C09 nerve blocks show improved components of fast track surgery pulmonary function, decreased have the greatest impact. Surgeons must understand and cardiovascular demand, and a lower address factors that keep patients incidence of ileus. Infiltration of hospitalized after major surgery. local anesthetics into the surgical 8 Critical Care ast track surgery involves wound is an effective analgesia F coordinated, multidisciplinary care to reduce complications, technique for minor surgical procedures. Maintaining normother- 22 Nutritional Support facilitate earlier hospital discharge, mia is critical, and using active and ROLANDO H. ROLANDELLI, MD, FACS and permit faster recovery. The passive warming devices decreases Professor of Surgery, University primary goal of this approach is not the incidence of wound infections, of Medicine and Dentistry of New cost containment through the blood loss, myocardial ischemia, and protein breakdown. An intra- Jersey Medical School, Newark, NJ reduction of hospital stay. The primary goals are to shorten operative fluid management strategy recovery time, decrease morbidity, remains controversial, as adverse continued on page 5 outcomes may be associated with and improve efficiency. both inadequate and excessive fluid Preoperative, Intraoperative, administration. Finally, surgical incisions should be as small as Coming in September and Postoperative Phases of possible while allowing adequate 5 Gastrointestinal Tract and Abdomen exposure, using laparoscopic 29 Intestinal Anastomosis Fast Track Surgery techniques when possible. everal preoperative elements can 2 Head and Neck S be addressed. For example, As relates to postoperative elements, pain remains the most 3 Neck Mass
  5. 5. What’s New in ACS Surgery 5 BRIAN K. SIEGEL, MD, FACS Enteral and Parenteral patients must receive extensive evaluation, teaching, and training if Staff Physician, Department of Nutrition home parenteral nutrition is to Surgery, Division of Trauma/Critical arenteral and enteral nutritional Care, Morristown, Memorial Hospital, Morristown, NJ P support is a valuable adjunc- tive—and sometimes life-saving— prove successful. therapy in the management of Nutritional Pharmacology DOI 10.2310/7800.S08C22 he role of nutrient administration Nutritional support is required in patients with various disease selected types of patients. Enteral nutrition is the provision of liquid- T has evolved from the maintenance of a positive energy and nitrogen formula diets by mouth or tube into processes. the gastrointestinal tract. Enteral balance to the use of nutrients to utritional support is required in nutrition should be prescribed only modulate tissue metabolism and N patients with various disease processes: a patient who has been if safety and a low complication rate can be ensured, and the appropriate organ system function. This new role is referred to as nutrition without nutrition for 10 days, one diet must be selected based on the pharmacotherapy. The most critical patient’s nutrient requirements. If nutrients include glutamine (the whose duration of illness is expected enteral nutrition cannot be tolerated main source of fuel for cells of the to be more than 10 days, and one (evidenced by vomiting, abdominal gut and immune system), arginine who is medically considered cramps or distension, etc.) or there (required for growth), purines and malnourished. is risk of aspiration, parenteral pyrimidines (essential for cell nutrition is recommended. proliferation), and fatty acids Nutrient Requirements for Ill Parenteral nutrition is often (generally used as fuel). Patients indicated in critically ill patients, and can be via central venous or, he energy requirements of an General Recommendations T individual are primarily related to body size, age, gender, and energy less commonly, peripheral venous infusions. Central venous solutions for Nutritional Support are commonly combinations of nutrition screening incorporating expenditure of activity (muscular work). In hospitalized patients who dextrose and an amino acid mixture to which electrolytes, vitamins, and A objective data (height, weight, primary diagnosis, etc.) should be a are generally inactive, the basal trace elements are added. For component of the initial evaluation. metabolic rate accounts for peripheral venous solutions, slightly Any patient identified as being the greatest amount of energy hypertonic nutrient solutions can be nutritionally at risk should have a expenditure, which is influenced by prepared from commercially formal nutrition assessment. the disease process. After energy available amino acid mixtures, Additionally, recommendations for requirements are determined, dextrose solutions, and fat specific disease states (cardiac, protein needs are calculated. The emulsions. pulmonary, liver, and renal disease; requirements for vitamins, minerals, Home parenteral nutrition is pancreatitis; short-bowel syndrome; and trace elements are usually met indicated for patients who are inflammatory bowel disease; solid when adequate volumes of balanced unable to eat and absorb enough organ transplantation; and burns) nutrient formulas are provided. nutrients for maintenance. However, should be followed.