Minimally Invasive Surgery And Why Do I Hurt?

Many of you may know that minimally invasive surgery offers many advantages to the patient. Maybe I should back up and explain what this is. In layman's terms, minimally invasive surgery is the performance of surgery without a big incision. We use very small incisions and cameras to carry out various procedures. The benefit to the patient may be less pain, getting back to the activities of daily living quicker, getting out of the hospital quicker and of course getting back to work in a more timely manner.

While this type of surgery has advantages for the patient, it can be rather taxing on the surgeon. The cases are longer, the instruments often have to be held in the same awkward position for long periods of time, and some of the ways in which the instruments are gripped are rather uncomfortable. In fact, many surgeons have experienced discomfort and pain in the arms, wrists, legs and back since starting to perform minimally invasive surgery.

A new study out of the University of Maryland in Baltimore has come out indicating that a significant occupational hazard exists with minimally invasive surgery. To review the details of the study, click here. In the study, 80% of surgeons reported stiffness in back, hands and legs when performing minimally invasive surgery. These symptoms can occur after or during surgery.

I think there are important things to consider when reviewing these findings. First, more and more procedures are becoming minimally invasive. So we can expect more and more problems related to this occupational hazard. Second, there are actual fields that all they do is minimally invasive surgery, so these surgeons are at an even higher risk.

I think that the research and development that goes into minimally invasive surgery will eventually focus mainly on ease of use of the instruments and comfort level while using the instruments. I can see surgeons in the very near future choosing instruments by not only how they perform the surgery, but also how easy and comfortable the instrument is to use. Currently, we care more about how the instrument functions, but as the instruments get to a certain high level of performance during the evolutionary process, the focus will indeed change.

Chlohexidine Cuts Risks Of Surgical Infections

Surgical procedures, as you may know, can be classified based on the degree of conatmination. A simple hernia repair may be a clean procedure while a colon resection may be a clean-contaminated procedure. As such, the incidence of infection is higher in the latter group.

While surgical antisepsis has come a long way, infections are still common. Scrubbing the abdomen with an iodine-based solution has been the standard for a long time. The overwhelming majority of surgical abdomens are prepared in this fashion.

New research is coming out suggesting that a chlorhexidine preparation is more effective than an iodine-based preparation in reducing postoperative infections. Please click on the above link to read the article on Medpage. This study was recently published in the New England Journal of Medicine.

While all studies, including this one, have their limitations, we may very well see a shift from the standard iodine-based preparation to the chlorhexidine preparation.

And So It Begins

It has been quite awhile since I have updated this blog. I have been trying to focus on more clinical information rather than politics and policy. However, I felt that this most recent topic couldn't be ignored and hence I shall share it with you.

As you are aware, the Senate and the House are getting ready to wave their magic wands and stir the healthcare pot to produce some kind of unknown offspring. How will the nation pay for this healthcare reform? One answer may be significant cuts in Medicare.....cuts for hospitals, drugs, equipment, nursing homes,and doctors.

The Obama administration contiues to look to the "The Mayo clinic model" in reshaping healthcare. If you are unaware of this model and why The Obama administration points to it, click HERE. You will be interested to know, that there is a Mayo Clinic facility in Arizona which will STOP taking Medicare patients starting next week. The clinic is saying that the reimbursement is signifcantly lower than that of private insurers and they cannot continue to provide care and run the clinic based on Medicare rates.

Unfortunately, this will force 3,000 patients to either pay out-of-pocket or find a different doctor. It really is a no win situation for everyone involved. The patient's have to find care elsewhere and the clinic doctors have to turn people away in order keep the practice running.

So essentially, the Mayo Clinic, which is what the Obama administration is looking to in shaping healthcare reform, is droppig out of Medicare. I really do think this is the beginning of a larger trend. More and more facilities and clinics will be forced to stop accepting Medicare....much like they already do with Medicaid. It's still a watch and wait situation.....but I think the move in Arizona speaks volumes.

Is Primary Colon Cancer A Different Disease Than Metastatic Colon Cancer?

New research is shedding light on primary colon cancer and metastatic colon cancer. One would think that the genetic makeup of of the two tumors is the same as one came from the other. However, research is showing that in fact, there are significant genetic differences between primary colon cancer and metastatic colon tumors. This may have significant implications in regards to treatment.

The research out of the Clevland Clinic looked at 47 stage III tumors and looked at the primary tumors and the nodes themselves. There were significant differences in microsatellite instability (MSI) and CpG island methylator phenotype (CIMP). One of the more significant findings in this study was that 54% of the 13 primary tumors that were CIMP-positive, were assocciated with nodal metastasis that was CIMP-negative. The study was conducted by Dr. Matthew Kalady of the Clevland Clinic. A summary has been recently published in General Sugery News. Dr. Matthew Mutch, from Washington University, provides a nice commentary on the study's implications.

So while it's early, the question becomes, do we treat the primary disease and the metastatic disease as two different diseases? Will there be chemotherapy that is aimed at the primary disease and a different treatment regimen aimed at the metastatic disease? Look for some interesting developments down the line in regards to future treatment protocols.

Medicine: France versus the United States

I just read a great article by a doctor who describes medical training in France and compares it with that in the United States. It's a short article and I think you might enjoy it. Click here if you are interested in reading it.

I thought it was interesting how the author made the point that American medical students have over $150,000 in debt when training is finished while French students go to school for free. By the was, this is one of the reasons American students specialize rather than go into primary care...they can't afford to practice primary care.

The other point I found interesting was how the author stated that if American medical education was government funded, the education would be more homogenous but less innovative. With less innovation, America would surely lose their place as the most medically advanced country in the world.

There are obviously many issues that this article does not discuss....like how America can be so innovative yet not be able to provide health care for ALL of its citizens. But the points that it does bring up are noteworthy.

Douglas Elmendorf: How Will He Effect Your Future?

Democrats, Republicans, Moderates, Conservatives, left field, right field, etc.... everyone has an opinion on health care and most are sounding off. Health care reform continues to keep people guessing. As you may be aware, the house did pass a bill recently by a rather narrow margin. At some point the debate will start on the Senate floor where the gauntlet promises to be much more rigorous.

While all players in the health care debate continue to argue, everyone has one eye on Douglas Elmendorf. As the head of the Congressional Budget Office (CBO), Mr. Elmendorf is a powerful figure in the health care debate....only he is not debating. Instead, his office crunches the numbers behind the bills. If the numbers make sense, dollars are saved, the defecit stays in check, all (or the majority) of Americans are insured and there is money to pay for the gigantic bill, then the Democrats and the Obama administration is happy and things move along smoothly.

If the numbers he crunches don't make sense, the costs are too high, too many Americans go uncovered or there's not enough money to cover the bill, then the waters gets choppy and health care reform can stall....even permanently.

So it's no wonder that all eyes are on Mr. Elmendorf. Recent reports are saying that his relationships with his Democrat friends have been strained.. Fortunately, it appears as if he is taking the high road and not playing favorites. “I can’t lead C.B.O. to reach conclusions to make particular friends of mine happy,” he recently said.

While all sides to the health care debate have wants, needs and demands, nothing can be realized unless the reform makes sense AND can be paid for. Believe it or not, this is rather difficult to achieve. Hopefully Mr. Elmendorf will continue to perform a detail-oriented job and sift out the truth behind the thousands of pages of legislative tangle.

Antidepressants and Colon Cancer: New Prevention Strategies On The Horizon?

There is new evidence coming out showing that antidepressants such as serotonin reuptake inhibitors (SSRIs) and possibly tricyclic antidepressants (TCAs) may inhibit colorectal tumor cell growth. The most recent findings were presented at the 2009 American Society of Preventitve Oncology by the Group Health Research Institute out of Seattle. The study is founded on the idea that SSRIs have been shown to play a role in hematosis and inhibition of growth of colorectal tumors that are dependent on serotonin for cell growth.

The study was a case-control analysis of 641 patients using antidepressants and 641 control subjects. Research looked at the use of antidepressants in the 10 years leading up to diagnosis of colon cancer. People who started taking antidepressants one year prior to diagnosis were excluded as they were deemed as not having long enough exposure to the antidepressant to consider being protective.

Twenty perecent of the cancer case patients and 24% of the control patients used antidepressants for a median of 1.8 and 1.1 years, respectively. The use of antidepressants was associated with a 30% decrease in the risk of developing a colorectal cancer.

In 2006, Dr. Jean Collet reported in Lancet Oncology a study of 3,367 cancer patients and a similar number of controls. They actually found that there was a decrease in the development of colorectal cancer with the use of SSRIs but not so much with the TCAs (Lancet Oncol 7:301-308, 2006).

It is quite obvious that in general, antidepressants are safe....as they are already widely used. Now the question becomes, what doses should be administered and which patient populations would receive the most benefit from the use of antidepressants to reduce the incidence of colorectal cancers. Much more investigation will be required before any (if at all) recommendations and guidelines can be made.

More May Actually Be Better: The 80 Hour Work Week In Question

When I was a resident, there was no such thing as an 80 hour work week. In fact, the 80 hour work week was instituted one year after I finished. It is safe to say that the average General Surgery resident worked far more than 80 hours per week prior to 2004. For those of you who don't know, medicine and surgery residents are now limited to working no more than 80 hours per week. The thought is that residents will be less tired and therefore make less mistakes. In the end, the hope was that patients will be safer and perhaps care would be better.

Unfortunately, that's not the reality we are seeing. Numerous studies have shown that patients are no safer since the new hour limits were instituted. One study clearly shows a higher incidence of complications after routine hip surgery. A different study shows that surgery residents avoid doing complex, lengthy cases and instead do the "bread and butter" cases. The cause of this is that residents need to avoid the long cases so they don't rack up too many hours. The downside of this is that residents are finishing their training unprepared. The details of these studies appeared recently on Medpage.

With the limited hours residents are working, there really is no continuity of care. While one resident may admit the patient through the emergency room and then go ahead and perform surgery, a different resident may be taking care of the patient postoperatively. This being the case, how does the resident learn to take care of his patients after surgery? Indeed continuity of care is crucial to the learning experience.

In case you were wondering, the 80 hour work week is strictly enforced and programs who violate the rules can be placed on probations and can ultimately lose their residency program all together. In light of these new studies some obvious changes may be in store. Without increasing the number of hours worked per week, there really aren't many options. The one obvious option would be to extend the amount of time it takes to complete training.

This is not as easy as it sounds as medical students are not too keen on spending more time training as it is already a lengthy process. In addition, as the cost of medical schools goes up and practice reimbursement goes down, it just doesn't make sense to dig your own grave.

I find it difficult to believe that surgery residents finishing training these days are as prepared as those who were not confined by the 80 hour work week. In the end, I think patient care is suffering. Older and more expereinced surgeons will tell you that their younger collegues just don't have what it takes coming out of training. In the end, patient safety may be better off  if doctors spent either more hours in the day training....or perhaps increasing the total time trainig.......Don't Shoot The Messenger!!!

H. pylori and Inflammatory Bowel Disease: Has Epidemiology Found A Connection?

One of the great dilemmas in colorectal surgery as well as gastroenterology is the etiology of inflammatory bowel disease (IBD) such as ulcerative colitis and Crohn's disease. To date we really have no idea what causes these diseases and as a result we have no medical cure for them. Medical therapy revolves around controlling the disease and not curing it.

So it's not unreasonable to ask ourselves why these diseases develop....especially when we spend a considerable amount of time treating them. Dr. Amnon Sonnenberg, a Gastroenterologist out of Portland, Oregon, has indeed come up with a hypothesis.

As we better came to understand the relationship between peptic ulcer disease and H. pylori, the prevalence of this infection decreased dramatically. Dr. Sonnenberg hypothesizes that the sudden decline of H. pylori precipitated an epidemic of inflammatory bowel disease. He outlines his theory in the September 2009 edition of Practical Gastroenterology.

His hypothesis rests on peculiar time trends in regards to the incidence of inflammatory bowel disease versus H. pylori infection. Large patient databases in Australia, Austria, England, Sweden, Switzerland and the United States were used to depict these trends. When studying these large databases graphically, it's obvious that the rise of the IBD epidemic started with the fall in the prevalence of H. pylori infection.

The trends would suggest that the H. pylori organism may in fact provide a protective mechanism against the development of IBD. The article in no way attempts to answer the exact mechanism by which this occurs, but instead provides an epidemiological argument for why this may be the case. Dr. Sonnenberg does state that the relationship may in fact be multifactorial and even coincidental.

In the end, when we don't understand the nuts and bolts behind why something may be, it may be of benefit to look at a much larger epidemiological picture to capture a trend that we can then focus in on.

Back To The Drawing Board!

"To: All Fellows of the American College of Surgeons


Thank you to all of you who made phone calls in support of S. 1776 - the "Medicare Physician Fairness Act of 2009." Unfortunately, earlier this afternoon, the United States Senate voted 47-53 on the motion to move to consideration of S. 1776. To be successful, 60 votes would have been necessary. The major objection of those who voted "no" was that the bill was not paid for by either offsets or increasing revenue."

By now, most health care professionals have received the above email. It was sent out shortly after S. 1776 failed. This is the latest embarrassment for the AMA which spent seven figures trying to get the bill passed.

The good news is that a separate motion passed which delayed the Medicare cuts for another year. Kind of sounds familiar doesn't it?

It's now apparent more than ever, that health care professionals are in it by themselves. It will take a much larger effort than the one just put forth in order for a permanent fix to take place in regards to Medicare cuts. What will have to happen in order for Congress to start taking health care professionals seriously?

Doctors denying Medicare? Hospitals denying Medicare? Everyone denying Medicare? Obviously this is not what we want. It's not good for patient care.

My solution: If the government wants to continue to reduce Medicare spending, doctors should drop it all together. Medicare will soon end up looking like Medicaid and doctors will end up paying to stay in business. Institute fee-for-service in lieu of Medicare and call it a day.

Long Term Consequences Of Preoperative Radiotherapy For Rectal Cancer

There are several studies that look at the effects of preoperative radiotherapy in regards to local recurrence and long term survival in patients with rectal cancer. The Multicenter CRO7 trial previously determined that the three-year local recurrence rates were significantly lower in those who underwent preoperative radiotherapy than in those who did not (4% vs. 11%). Disease-free survival and overall survival rates were also higher in the preoperative radiation group.

This of course is the good news. The bad news is the corollary to the previously reported findings of the Medical Research Council CRO7 trial. The corollary states that patients randomized to be treated preoperatively with a short course of radiotherapy were more likely to report impaired male sexual function and unintentional release of stools at two and three years than those who did not receive the preoperative therapy. These results are similar to a Dutch study which was published in 2005.

All study patients had operable, nonmetastatic disease of the rectum; 73% were male. Patients in the preoperative group received five daily fractions of 5Gy each prior to surgery.

Surgery itself can cause nerve damage which can play a role in both sexual and bowel dysfunction. The mechanism by which radiation causes problem is not fully understood, but may be related to microvascular damage. Obviously, not all patients had adverse outcomes, as of now, we cannot predict who will have issues and who will not.

Perhaps as the studies mature further, investigators will be able to better understand which populations of patients are at a higher risk. As for now, like in all other areas of medicine, we will have to continue to weigh the risks and the benefits, practice evidence-based medicine and communicate fully with patients so we can help them make sound medical decisions.

Does Health Care Reform = Malpractice Reform?

At this point I would definitely say that we are in the fourth quarter in the process of passing health care reform. Don't worry, both sides have plenty of time outs and neither side has used its challenge yet. As the bill in the Senate picks up steam, some interesting things are coming to light.

The Congressional Budget Office (CBO) recently came out with some numbers in answer to an interesting question. The question asked was what would happen if there were a national cap on punitive and noneconomic damages as well as other new rules that could limit doctors’ liability exposure? We all know very well, that this is a difficult number to come up with....after all, how do you accurately quantitate the effect of defensive medicine?

By instituting national caps, the CBO found that the nation’s total health bill would be lowered by about 0.5%, or $11 billion a year at current spending levels. That includes 0.2% in savings from lower direct spending on malpractice, and 0.3% in savings as a result of less defensive medicine. This would be a savings for the government of $54 billion over 10 years. See what the WSJ had to say.

Here's where it gets interesting. As I blogged before, doctor salaries account for only 1% of all health care dollars spent each year....if you're wondering, that's $26 billion annually. The CBO just said that instituting caps on malpractice claims would save $11 billion annually. So in essence, the cost of malpractice claims and defensive medicine is approaching half of what all doctors make in this country......That's a lot of money.

While there are several critical issues that doctors should pay attention to as health care reform takes shape, limiting medical malpractice liability is a crucial component. Let us not lose sight of the fact that as soon as we can concentrate on practicing sound, evidenced-based medicine WITHOUT having to turn our heads and look behind us every step of the way....then and only then will we again make our profession not only fun and exciting....but also save health care dollars at the same time.

Minimally Invasive Surgery, Marketing And Ethics

The buzz around the American College of Surgeons meeting in Chicago has certainly reached a peak as the meeting starts in less than a week. I have been talking with various colleagues who are colorectal surgeons and who are planning on attending the meeting. While there is not an overwhelming amount of content at the meeting that is aimed at the average colorectal surgeon....there is some.


Like the annual ASCRS meeting, there will be a considerable amount of products that pertain to minimally invasive colon resections. In fact the "new" thing right now is single port laparoscopy. Both Covidien and Olympus have recently launched new products. These new products are conveniently advertised in Gastroenterology & Endoscopy News.....just in time for the meeting in Chicago.

Of interest is what my colleagues had to say about this new technology. I will preface this by saying that some have not yet begun to perform single port surgery and some have dabbled in it. What was interesting is that most stated that it was basically a marketing ploy. In other words, if you use one 12mm port and two 5mm ports to do a laparoscopic right resection, that there is no significant advantage in using a large single port technique. The same comments were expressed for the left side as well. In regards to evidence-based medicine....well...the evidence hasn't been looked at yet.

Sure, performing single incision surgery is another way to take the colon out. But really, it's good advertising. Is the incidence of ileus going to be less than multiport laparoscopy or hand assisted procedures? Will patients leave the hospital quicker or return to work earlier? The answer is probably no.

By the way, at the ASCRS meeting in Florida this year I overheard some of the sales representatives for robotic surgery talking to a couple of surgeons. The sales pitch basically revolved around how when you advertise that you use robots, the referral numbers "go through the roof." It sure would have been nice to hear that there was actual benefit to the patient instead of the referral numbers.

Just how far will we go and what is the next best thing? Surgery is constantly pushing the envelop and I would not expect it to stop anytime soon. The question now becomes, are we actually making it better or are we cutting the pie into more slices? What I don't want to see with colorectal surgery...or for that matter any field of surgery, is advertising procedures for market appeal. It seems so unprofessional.

I do think it's nice to have an arsenal of weapons when performing. If there are several different ways to get the same result, I see nothing wrong with that. I do find it misleading to advertise that one is better than the other when it really may not be. In fact, many of these procedures are far more expensive than their counterparts.

We hear a lot about ethics in the way we treat colleagues and patients. I do believe that this should apply to how we inform the public of different treatment options.

Hospitals, Complications And Mortality

Complications happen....so does death. Unfortunately these things are unavoidable in medicine. A surgeon can do the same exact operation a dozen times and one of those times something may go wrong in the postoperative period. Maybe the patient gets a wound infection or pneumonia....maybe it's a heart attack.

What is interesting is that there is literature coming out that states that while the complication rates may be the same from one institution to the next, the mortality rates are different. This is exactly what investigators from The University of Michigan at Ann Arbor found. Take time to read about the study here.

In essence what this study is saying is that some hospitals do not identify and successfully treat complications thereby causing higher mortality rates. In the study, hospitals with the highest mortality rates had a 24.6% rate of complications and an 18.2% rate of major complications, compared with 26.9% and 16.2%, respectively, for hospitals with the lowest mortality rates. So you can see that complications were similar.

HOWEVER, in hospitals with the highest mortality, the risk of dying of a postsurgical complication was 21.4%, compared with just 12.5% in the facilities with the lowest mortality rates.

In summary, while complications do occur, it is how we reaily identify and treat them that makes the difference. Not doing so can very well mean a higher mortality rate.

Dirty, Rotten, Swine!!

Like the rest of the nation, I've been worried this Flu season. With the alarm bells ringing everyday warning the public about the coming of Swine Flu, it's hard not to be scared.

Fortunately, the warnings are not going unheard. Most of colleagues are taking to steps to protect their employees as well as their patients. In my opinion, it is pure ignorance not to implement the steps that The Center for Disease Control (CDC) has come up with. After all, these are the people who make it their job to know how to control and treat these problems. For the latest information on Swine Flu, click here.

In my office, the office staff will inquire about flu symptoms when they call patients to remind them of their appointments. If a ptaient thinks they have symptoms then the staff will reschedule them if feasible. Hand sanitizer and masks are available inside our waiting room. The receptionist asks patients checking in about flu symptoms. If they do have symptoms or if the receptionist suspects there are symptoms, then she will get the office manager.

The office manager will then make a decision to either reschedule the patent's appointment or perhaps the problem is serious and they need to be seen. In the latter case, contact and respiratory precautions will be put into place for that patient.

If for some reason these first defense mechanisms do not pan out then there is a sign in each patient room outlining what the symptoms of the flu are and to tell the doctor if you think you have them. Lastly, there is hand sanitizer in each exam room as well as in the actual doctor offices in the back.

As far as the flu vaccine is concerned, unless there is a documented medical reason why an employee or employer can not have the vaccine, I see no justifiable reason why everyone shouldn't be vaccinated. If the CDC, National Institute of Health (NIH) and The World Health Organization (WHO) are recommending these vaccines and have actual guidelines about who needs them, I see know reason not to follow them to the letter.

Like most things in life, we can reach a goal if we work together as a team and not cut corners....kind of like the actual practice of medicine itself.