Two senior surgeons' view: prevention of surgical site infection associated with colorectal operations.

Preventing surgical site infection is perhaps the most direct method of decreasing medical expenses. The following is an attempt at comprehensive ways of decreasing surgical site infection as well as decreasing patient discomfort.

Hernia repair: why do we continue to perform mesh repair in the face of the human toll of inguinodynia?

Fifteen to 20 years ago, transversalis and Shouldice Hospital repairs were standard, with a 4% to 6% rate of recurrence. With a focus on recurrence, various mesh repairs were proposed to reduce the incidence of recurrence. With these repairs, an increased incidence of inguinodynia due to the entrapment of the nerves proximate (adjacent) to the mesh has been observed. Many surgeons doubted its existence; however, there is sufficient evidence that with mesh repair in which the affected nerves are resected, the incidence of severe pain is lessened considerably. Triple neurectomy has been proposed as a therapy, but only 80% of patients are relieved of pain. Recurrence is insufficient to make patients' lives miserable, with mesh repair reporting up to a 21% incidence of inguinodynia. Although few surgeons today perform this procedure and most residents have never seen it, the author proposes that mesh repairs be abandoned and the transversalis or Shouldice Hospital repair be adopted.

The implications for the surgical community of bariatric surgery as a "cure" for type 2 diabetes.

The United States is in the throes of an epidemic of morbid obesity and, parenthetically, type 2 diabetes. Recent data indicate that bariatric surgery, notably Roux-en-Y gastric bypass, is valid not only for weight loss but also for a high success rate in the amelioration and perhaps "cure" of type 2 diabetes. It clearly is not weight loss alone, because the amelioration of type 2 diabetes occurs before weight loss. The mechanism needs to be elucidated and researched. For the first time since tuberculosis--before antitubercular drugs, when surgical procedures were the principal mechanism for dealing with tuberculosis--surgery has the opportunity to participate in the amelioration and perhaps cure of this epidemic and to regain its professional stature. Included in this article are the author's thoughts and suggestions on how we can keep control of weight loss and bariatric procedures that are valid treatments for morbid obesity and related type 2 diabetes. We should use this opportunity to stop the current conversion of surgeons from professionals to employees.

Staying alive: strategies for accountable health care.

The Patient Protection and Affordable Care Act signed into law in March 2010, has led to sweeping changes to the US health care system. The ensuing pace of change in health care regulation is unparalleled and difficult for physicians to keep up with. Because of the extraordinary challenges that have arisen, the public policy committee of the Society for Surgery of the Alimentary tract conducted a symposium at their 52nd Annual Meeting in May 2011 to educate participants on the myriad of public policy changes occurring in order to best prepare them for their future. Expert speakers presented their views on policy changes affecting diverse areas including patient safety, patient experience, hospital and provider fiscal challenges, and the life of the practicing surgeon. In all areas, surgical leadership was felt to be critical to successfully navigate the new health care landscape as surgeons have a long history of providing safe, high quality, low cost care. The recognition of shared values among the diverse constituents affected by health care policy changes will best prepare surgeons to control their own destiny and successfully manage new challenges as they emerge.

Nutritional support: we have failed in our ability to support patients with sepsis and cancer.

Despite the success of both parenteral and enteral nutrition in supporting patients who cannot eat, patients with either sepsis or cancer cannot be adequately supported. A proposed mechanism by which aerobic glycolysis leads to a shortage of energy production in the liver is discussed. According to this hypothesis, the proximity of sodium-potassium ATPase and glycogen, its fuel source, leads to the continuation of gluconeogenesis with continued proteolysis and muscle wasting. Myostatin and lipokine, newly discovered factors, may also play a role.

Edward D. Churchill as a combat consultant: lessons for the senior visiting surgeons and today's military medical corps.

In World War II, Edward D. Churchill volunteered as a combat consultant. In this role, he mentored many junior surgeons and challenged the Army leadership to treat hemorrhagic shock with blood rather than plasma. These lessons have continued relevance for today's Senior Visiting Surgeons and our military medical corps.

Historical perspectives in the care of patients with enterocutaneous fistula.

Evidence can be found throughout surgical history of how devastating an enterocutaneous fistula (ECF) can be for both patient and surgeon. From antiquity, this complication of abdominal surgery, malignancy, radiation, trauma, or inflammatory processes has been a significant challenge to surgeons due to high associated mortality and significant morbidity. An ECF causes dehydration, malnutrition, skin excoriation, and sepsis, and has profound psychological effects on the patient. Recent mortality rates of patients suffering an ECF approach 20%. The authors illustrate the history of management of patients with ECF and discuss advances in perioperative care including parasurgical care, nutrition, wound care, and the history of surgical techniques.

Is damage to the common bile duct during laparoscopic cholecystectomy an inherent risk of the operation?

Laparoscopic cholocystectomy has been practiced for close to 20 years. The rate of common duct injury remains somewhere between 0.4 to 0.7 percent and is approximately the same around the world. Recent papers have stressed ways in which laparoscopic common duct injury can be avoided, but none of the methods mentioned is foolproof. In addition, this complication can occur to even the most experienced laparoscopic surgeon. The author believes that injury to the common duct during laparoscopic cholocystectomy is not a result of the practice below the standard, but an inherent risk of the operation. This injury needs to be emphasized by the surgical community as an inherent risk of the operation, and patients should be fully informed of this potential complication.

How I do it: gastrointestinal cutaneous fistulas.

INTRODUCTION: Gastrointestinal cutaneous fistulas are among the more complex surgical conditions, with mortalities in the current series between 6% and 20%, and in some non-U.S. series, up to 40%. The series of principles of recognition, preparation of the abdominal wall, enteral and parenteral nutrition, and support, is outlined. Diagnosis in the absence of signs of sepsis is usually obtained by a fistulagram done by collaboration between the senior surgeon and the senior radiologist and followed to make certain that there is no intestinal obstruction. If spontaneous (nonoperative) closure does not occur in 5 to 6 weeks, it is unlikely to occur and an operation will be required. In our experience, obliterative peritonitis does not subside until a minimum of 4 months, and so an elective operative approach should take place when required after 4 months since the previous operation (when the fistula occurred). METHODS: A technical approach to operation is described. Avoiding enterotomies is critical. The abdomen should be entered in a fresh area, either by an extended incision, or in a virgin area transversely, if the previous incision was vertical and occupied the entire length of the abdomen. It often takes between 1.5 and 2 h to get into the abdomen without making additional enterotomies. The goal is to dissect laterally in one area until one enters a free lateral space which is free of adhesions. One then proceeds from lateral to medial to take down the adhesions from the previous incisions. When one is finished taking down these adhesions, it is usual that only 12 to 18 in. of bowel of the fistula and the surrounding enterotomies requires resection. An end-to-end anastomosis should be performed. Our practice is a two-layer silk-interrupted anastamosis. Adjunctive steps following the operation usually include a gastrostomy and a catheter jejunostomy. In order to be successful, the best results are obtained with a native abdominal wall closure with either component separation or an Abrahamson-type closure. If this cannot be achieved, multiple layers of vicryl are used, which usually enables the fistula to heal; a hernia usually results, but that can be dealt with at some future time. Using these principles, the last 50 cases at our personal series have been done without mortality.

The importance of reconstruction of the abdominal wall after gastrointestinal fistula closure.

Operation for gastrointestinal cutaneous fistula almost always requires resection and anastomosis. Those of use who do this surgery frequently have learned the hard way that closure of the abdominal wall, preferably with native tissue, is essential for refistulization to not occur. What is one to do when component separation or an Abramson type of approach is insufficient and flaps either can not be done or are not available? Recently, it has been proposed that inert biological material may be the answer for abdominal closure and somehow it is more resistant to infection and less likely to fistulize than totally synthetic material. However, data has slowly been coming available that suggests that use of inert biological material may in fact not be satisfactory and may in fact have an increased tendency to infection, wound breakdown, and refistulization.

A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development.

During the past several years, vacuum-assisted closure (VAC) systems have been increasingly used in the treatment of gastrointestinal cutaneous fistulas, particularly those associated with open abdomen. Recently, I experienced 2 cases in which the original fistula closed after treatment by the VAC system. However, these patients, who had exposed bowel, developed an additional fistula that required surgery. In a recent article from an intestinal-failure unit in the United Kingdom, Rao et al(1) reported on a series of 29 patients treated with VAC, 6 of whom developed new gastrointestinal cutaneous fistulas. Four of these 6 patients died. My own experiences, plus the report of Rao et al,(1) suggest the possibility that the use of the VAC system in patients with exposed bowel and an open abdomen may be associated with subsequent fistula development. Although the numbers are small, it also raises the question that development of a fistula in a patient treated with VAC may result in higher mortality.

Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways.

BACKGROUND: Although clinical pathways were developed to streamline patient care cost efficiently, few have been put to rigorous financial test. This is important today, because payors demand clear solutions to the cost-quality puzzle. We describe a novel, objective, and versatile model that can evaluate and link the clinical and economic impacts of clinical pathways. STUDY DESIGN: Outcomes for 209 consecutive patients undergoing high-acuity surgery (pancreaticoduodenectomy), before and after pathway implementation, were examined. Four grades of deviation (none to major) from the expected postoperative course were defined by merging length of stay with a validated classification scheme for complications. Deviation-based cost modeling (DBCM) links these deviations to actual total costs. RESULTS: Clinical outcomes compared favorably with benchmark standards for pancreaticoduodenectomy. Despite increasing patient acuity, this new pathway shortened length of stay, reduced resource use, and decreased hospital costs. DBCM indicated that fewer deviations from the expected course occurred after pathway implementation. The impacts of complications were less severe and translated to an overall cost savings of $5,542 per patient. DBCM also revealed that as more patients migrated to the expected course within our standardized care path, 50% of overall cost savings ($2,780) was attributable to the pathway alone, and improvements in care over time (secular trends) accounted for the remainder. CONCLUSIONS: DBCM accurately determined the incremental contribution of clinical pathway implementation to cost savings beyond that of secular trends alone. In addition, this versatile model can be customized to other systems' improvements to reveal their true clinical and economic impacts. This is valuable when choices linking quality with cost must be made.