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Tag: Surgery

  • Timely Surveillance with Chest Imaging May Benefit Colorectal Cancer Patients

    Timely Surveillance with Chest Imaging May Benefit Colorectal Cancer Patients

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    Key takeaways: 

    • Up to 50% of colorectal patients may develop metastatic cancer that has spread to other areas of the body. 
    • One of the most frequent areas colorectal cancer spreads to is the lungs, affecting up to 18% of patients with colorectal cancer; these patients often face a poor prognosis, especially if caught at a late stage. 
    • New study investigated optimal timing intervals and key clinical factors, including genetic factors and tumor characteristics, that may reveal which patients are at risk for developing lung metastases. 

    Newswise — SAN DIEGO: Colorectal cancer patients with certain clinical characteristics may benefit from more frequent chest imaging to help identify and target cancer that has spread to the lungs, according to new research presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. These findings have the potential to improve long-term outcomes of patients with metastatic colorectal cancer. 

    Despite improved survival rates, colorectal cancer is the third leading cause of cancer-related deaths in the United States.1 Though rates of colorectal cancer have declined among people 65 and older, largely thanks to increased screening efforts, rates among younger adults are rising.2 When the cancer is caught early, many patients can remain disease-free for the rest of their lives after surgical treatment, but colorectal cancer can spread (metastasize) in up to 50% of patients.3 One of the most common areas colorectal cancer spreads to is the lungs, affecting up to 18% of patients with colorectal cancer.4 Detecting cancerous nodules in the lung early provides patients with the best outcomes, but there are no evidence-based standards for when and how often to screen colorectal cancer patients with chest CT or PET scans. 

    “After patients are diagnosed with colorectal cancer, many of them want to better understand what their cancer diagnosis entails in terms of their surveillance and survivorship for the rest of their life, but we currently lack data and uniform guidelines to support how often these patients should be screened with chest imaging,” said co-author Mara Antonoff, MD, FACS, associate professor, thoracic and cardiovascular surgery, UT MD Anderson Cancer Center, Houston, where she also serves as program director of education. “With this study, we sought to develop a strategy that is evidence-based to determine how frequently, at what intervals, and for how long patients at risk of developing lung metastases should undergo imaging of their chest.” 

    Dr. Antonoff specializes in thoracic surgical oncology and has a clinical interest in colorectal cancer that has spread to the lungs. She is leading a multi-institutional study, under the umbrella of the American Association for Thoracic Surgery (AATS) Thoracic Surgery Oncology Group (TSOG) (TSOG 103), on developing optimal treatment strategies for colorectal cancer patients whose cancer spread is limited to the lungs. 

    To identify which colorectal cancer patients may benefit from early chest imaging and at what time intervals, Dr. Antonoff and an interdisciplinary team of researchers at MD Anderson – including cardiothoracic surgeons, colorectal cancer surgeons, and gastrointestinal oncologists – collaborated on this research project to investigate evidence-based surveillance guidelines for colorectal patients who are at risk of developing lung metastases. 

    Study details 

    Using two MD Anderson cancer databases that included both colorectal cancer patients and thoracic cancer patients, the study team retrospectively reviewed data from patients with colorectal cancer who did and did not develop lung metastases. Patients were grouped according to the development of lung metastases and the timing of their diagnosis. The team used statistical methods to investigate which clinical characteristics, such as age or genetic factors, correlated most with the risk of developing lung metastases.  

    Key findings 

    • Of 1,600 patients with colorectal cancer, 233 (14.6%) developed pulmonary (lung) metastases, with a median time of 15.4 months following colorectal surgery.  
    • The team identified age, neoadjuvant or adjuvant systemic therapy (such as chemotherapy or immunotherapy), lymph node ratio, lymphovascular and perineural invasion (high-risk tumor characteristics observed under a microscope), and presence of KRAS genetic mutations as risk factors for developing lung metastases. 
    • Further data analysis revealed that patients who required systemic therapy around the time of their surgical operation for colorectal cancer, who had an elevated lymph node ratio, and a KRAS mutation, were at risk of developing lung metastases within three months of surgery. 
    • The authors concluded that these patients may benefit from more frequent surveillance with chest CT or PET scans. 

    Nathaniel Deboever, MD, general surgery resident, UTHealth Houston McGovern Medical School, and the lead author of the study, noted that while these risk factors are not necessarily surprising from a clinical perspective, they highlight the need to adequately screen certain colorectal cancer patients after surgical treatment. In some cases, removing cancerous lung nodules surgically early on can significantly improve outcomes. 

    “A concrete clinical application of this research, following validation, is to build evidence-based guidelines affecting chest surveillance in patients with resected colorectal cancer,” said Dr. Deboever, who completed this research as part of his research fellowship with the department of thoracic and cardiovascular surgery at MD Anderson. “These guidelines will hopefully allow high-risk patients to undergo radiographic screening in a timely manner, permitting the early diagnosis of pulmonary disease.” 

    Next steps 

    In future research, the team plans to validate findings in a separate group of patients, with the hope of formalizing chest surveillance protocols for widespread clinical adoption. Drs. Antonoff and Deboever noted that as colorectal cancer research evolves, sensitive blood tests to detect cancer or advanced radiographic screening methods using artificial intelligence may also play an important role in monitoring patients. 

    “There are many patients who receive cancer care outside of cancer hospitals, so having algorithms, pathways, and recommended protocols can be very helpful for providers who care for a lot of different diseases with rapidly changing recommendations,” Dr. Antonoff said. “I think this research is really just the tip of the iceberg.” 

    This study was funded by the Department of Thoracic and Cardiovascular Surgery at MD Anderson Cancer Center, which included financial support from the Mason Family Philanthropic Research Fund.  

    Study coauthors are Erin M. Bayley, MD, MS; Brian K. Bednarski, MD, FACS; and Van Morris, MD. 

    Dr. Deboever and Dr. Antonoff have no disclosures to report.    

    Citation: Deboever N, et al. Do Resected Colorectal Cancer Patients Need Early Chest Imaging? Impact of Clinicopathologic Characteristics on Time to Development of Pulmonary Metastases, Scientific Forum, American College of Surgeons Clinical Congress 2022.  

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    1Key Statistics for Colorectal Cancer. American Cancer Society, January 12, 2022. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html 

    2Colorectal Cancer Rates Rise in Younger Adults. American Cancer Society, March 5, 2020. https://www.cancer.org/latest-news/colorectal-cancer-rates-rise-in-younger-adults.html  

    3Leporrier J, Maurel J, Chiche L, et al. A population-based study of the incidence, management and prognosis of hepatic metastases from colorectal cancer. British Journal of Surgery 2006: 93(4), 465-474. 

    4Gonzalez M, Gervaz P. Risk factors for survival after lung metastasectomy in colorectal cancer patients: systematic review and meta-analysis. Future oncol. 2015: 11(2s):31-3. 

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    About the American College of Surgeons  

    The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.   

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  • Fewer patients sent to hospital rehabilitation facilities for recovery after colorectal operations early in the COVID pandemic

    Fewer patients sent to hospital rehabilitation facilities for recovery after colorectal operations early in the COVID pandemic

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    Key takeaways 

    • The first months of the COVID pandemic in 2020 caused a discernible change in post-surgery practice; colorectal surgeons discharged more patients direct to home for recovery, thus, bypassing a stay at a rehabilitation facility.   
    • The rate of patients discharged to rehabilitation facilities dropped 3% but the number of patients who were readmitted to the hospital with complications remained stable, even though patients underwent fewer minimally invasive procedures.  
    • Telemedicine visits rose among patients discharged home so care providers could check in on their patients. Study findings showing stable hospital readmission rates in pandemic year 2020 highlight the potential for lowering rehabilitation utilization for colorectal patients.  

    Newswise — SAN DIEGO: The first months of the COVID pandemic had a profound effect on hospital discharge practices and use patterns for patients with colorectal disease, according to findings presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. A study of more than 100,000 surgical patients who underwent procedures for colorectal cancer found that they had 40% lower odds of being discharged to post-hospital rehabilitation during the pandemic than before.  

    Despite this significantly lower rate, the hospital readmission rate did not change from pre-pandemic levels, said Marc Mankarious, MD, a surgical resident at Penn State Hershey Medical Center, Hershey, Pennsylvania. 

    “We found that discharge to a rehabilitation facility pre-pandemic was 10%, which agreed with previous literature, but once the pandemic hit, the discharge-to-rehabilitation rate dropped to about 7%,” Dr. Mankarious said. “We saw a drop of three percentage points, even though we were doing more emergent operations and more open operations, which are typical risk factors for requiring rehabilitation after surgery.” 

    The authors hypothesized that anecdotally, fear of going into confined spaces, staff and supply shortages, and disease outbreaks contributed to changes in discharge practices. 

    About the Study 

    The retrospective cohort study used two databases from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®): the Participant Use File and Target Colectomy databases. Researchers analyzed data on 116,677 patients: 90,250 from 2017 through 2019, and 26,427 from 2020. For comparison, the first quarter was excluded from all years because the first COVID restrictions did not go into effect until March 2020. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. It was created by surgeons to help hospitals gauge the quality of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information. 

    Key findings  

    • In comparing the pre- and post-COVID-19 periods, the proportion of emergent cases and open operations—as opposed to minimally invasive procedures—increased in 2020, from 13 to 15% (p<0.001) and 31 to 32% (p<0.001), respectively.  
    • A multivariable analysis found that patients in 2020 had 40% lower odds of going to a post-discharge facility (odds ratio 0.62, p<0.001), even after the analysis adjusted for reasons for having the operations and other medical conditions the patients had. 
    • The rates of patients going back to the hospital within 30 days of discharge was 10% in both periods (p=0.4). 

    Surgeons’ observations  

    The stability in hospital readmission rates was telling because that may be “one of the factors that goes into deciding whether to offer a rehabilitation stay to a patient,” Dr. Mankarious said. 

    The study data did not include reasons why patients did or did not choose to go to post-discharge rehabilitation to recover; the authors hypothesized that factors included limited availability of beds and patient concerns about visitor restrictions and contracting COVID-19 Dr. Mankarious said. But the pandemic saw a 63-fold increase in telehealth use in 2020 over 2019.* “This situation may have made patients and physicians more comfortable with the patient going home and following up with each other electronically,” he said.  

    The data included some information on medical reasons for going to rehabilitation. “We did find that patients that went to rehabilitation in 2020 were more functionally dependent or functionally impaired than patients that went to rehabilitation in previous years, so those factors may also play a part in it.” Dr. Mankarious said. 

    The study grew out of what surgeons at Penn State Hershey were observing in the early days of the pandemic, said senior author Audrey Kulayat, MD, assistant professor of colorectal surgery. “We wondered if those observations had an impact on a bigger scale other than just at our institution,” she said. “But then we wanted to know, what’s the downside? Was there a downside? Are patients getting readmitted more frequently as a result of going back to their home or whatever institution versus going to a place with a higher level of nursing care? We didn’t find that they were readmitted more often.”  

    Potential change in discharge practice  

    The study findings raise questions about the potential overuse of posthospital rehabilitation for colorectal patients, Dr. Mankarious said. “Medicare spends about $60 billion per year on patients going to post-acute care facilities or rehab in general and any small reductions, even our 3%  reduction, which was significant, could result in considerable cost savings for the healthcare system.  

    “And it really helps us rethink who should go to post-surgery rehab, maybe raise our thresholds as we become more comfortable sending patients home and have better utilization of the new available modalities to help us follow up with them without having to send them to rehab,” Dr. Mankarious added. 

    Dr. Mankarious and Dr. Kulayat have no disclosures. 

    Study co-authors are Austin C. Portolese, MD; Jeffrey S. Scow, MD, FACS; Michael Deutsch, MD, FACS; and Nimalan A. Jeganathan, MD, FACS, all of Penn State Hershey Medical Center.  

    Citation: Mankarious MM, et al. Changing Disposition Patterns of Colorectal Surgery Patients in the Era of COVID-19. Scientific Forum Presentation, American College of Surgeons Clinical Congress 2022.  

    ________________________ 

    * Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristic and Location. (Issue Brief No. HP-2021-27) Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; Washington, D.C.; December 2021. Available online.

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    About the American College of Surgeons 
    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Study finds less expensive noninvasive test is an effective alternative to a more costly test for colorectal cancer screening

    Study finds less expensive noninvasive test is an effective alternative to a more costly test for colorectal cancer screening

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    Key takeaways 

    • National guidelines suggest a fecal immunochemical test (FIT) can be used as the primary noninvasive screening modality for early-stage colorectal cancer, but a significant proportion of patients still receive a more expensive alternative test called Cologuard®. 
    • Data used for national screening guidelines has shown no difference between the two tests at detecting adenoma versus colorectal malignancy. 
    • These results align with previous studies out of Japan and the Netherlands examining FIT as an appropriate screening modality that is more cost effective than other types of noninvasive colorectal screening tests.  

    Newswise — SAN DIEGO: Commercially available noninvasive screening tests for colorectal cancer—a fecal immunochemical test (FIT) and the multi-target stool DNAtest (mt-sDNA; or Cologuard®)—are equally effective for screening patients with early-stage colorectal cancer. However, a FIT costs about one-fifth of the multi-target DNA test, according to new study results presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    Pavan K. Rao, MD, a general surgery resident at Allegheny Health Network in Pittsburgh, Pennsylvania, presented study results looking at 117,519 people in the Highmark claims database who underwent colorectal screening in 2019. Highmark is a Blue Cross Blue Shield Association insurer in four Mid-Atlantic states.   

    From that group, the researchers identified 91,297 people who had noninvasive screening with either the fecal immunochemical test (FIT, n=45,487) or the DNA test (mt-sDNA, n=46,110) instead of having a routine colonoscopy.   

    Key findings  

    • Among the study population that underwent colorectal screening, 45,487 (38.7 percent) had one of two commercially available FIT tests and 46,110 (39.2 percent) had the mt-sDNA test.  
    • Patients who were screened with either test presented with early disease, staged from 0 to II, at similar rates: 59.5 percent for FIT and 63.2 percent for mt-sDNA test (p=0.77).  
    • Patients within the Allegheny Health Network Oncology Registry diagnosed with colorectal cancer were matched to their claims data to determine distribution of cancer stage.  If the noninvasive test indicated signs of early disease, patients were then referred for additional testing to confirm the findings.   
    • The total annual costs for the tests were $6.47 million—$1.1 million for a FIT, or about $24 per test, and $5.6 million for mt-sDNA, or about $121 per test. Costs were calculated using Medicare reimbursement rates. 

    Observations on study results  

    The study followed guidelines issued by the U.S. Preventive Services Task Force (USPSTF) in 2016 and updated in 2019. Since then, the guidelines were updated again in 2021.1 

    “Despite national guidelines suggesting that FIT be used as the primary noninvasive screening modality, we found that on review of our insurer’s claims data, a significant proportion of patients still receive a more expensive alternative test. There is substantial cost savings not only to our patients but to our health system with promoting appropriate use of noninvasive testing,” Dr. Rao said. 

    “There was no difference in the clinical stage at the time of diagnosis between the two tests, which again demonstrates the clinical equipoise maintained by switching to FIT,” Dr. Rao said of the variation between the two tests.  

    He added, “When you look at the national data for which the guidelines put forward, they found no difference between the two tests at detecting adenoma versus colorectal malignancy.”2 

    Cost savings without compromising care  

    The researchers determined that transitioning all noninvasive colorectal cancer screening to FIT would result in a $3.9 million savings annually in the study population.  

    “In the current state of healthcare, we are thinking ever more about efficiency and reduction in costs while maintaining patient outcomes, and not compromising the quality of care we provide,” Dr. Rao said. “I think a colorectal surgeon or any specialist who sees appropriate patients for colorectal cancer screening can use this data to provide recommendations of alternative screening tests to patients who primarily do not want to undergo colonoscopy. We cannot only say it is appropriate from a guideline standpoint, but we’re also reducing wasteful spending in health care by appropriately using the FIT.” 

     What makes this study unique is the methodology used to analyze the claims data, said study coauthor Casey J. Allen, MD, a surgical oncologist at Allegheny Health Network and an assistant professor at Drexel University College of Medicine, Pittsburgh. The researchers analyzed outcomes in the local health registry and then applied those outcomes to the claims database. “It’s not just the cost of the mt-sDNA test kit or the cost of the FIT kit multiplied by the number of members in the healthcare system,” Dr. Allen said. “It’s the full downstream costs depending on the rates of false-positive and false-negative tests and how much it costs to obtain a colonoscopy when that occurs. The cost of a screening colonoscopy in the database the researchers used was $635. 

    These results support previous studies out of Japan3 and the Netherlands4 that found FIT was more cost-effective than other types of noninvasive colorectal screening tests.  

    Study coauthors are Samantha Falls, DO, Stacey Shipley, BA, and Katie Farah, MD, of Allegheny Health Network, Wexford, Pennsylvania; and Patrick L. Wagner, MD, FACS, David L. Bartlett, MD, FACS, and Sricharan Chalikonda, MD, MHA, FACS, of Allegheny Health Network, Pittsburgh.  

    Dr. Rao and Dr. Allen have no disclosures to report. 

    Citation: Rao, PK et al. Comprehensive Cost Implications of Commercially Available Non-invasive Colorectal Cancer Screening Modalities: Results of A Large National Insurer Claims Database Analysis, Scientific Forum, American College of Surgeons Clinical Congress 2022.  

    ________________________ 

    1U.S. Preventive Services Taskforce. Final Recommendation Statement, Colorectal Cancer: Screening. Updated May 18, 2021. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening (.) 

    2Rex DK, Boland CR, Dominitz et al. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017;112(7):1016-1030. 

    3Sekiguchi M, Igarashi A, Sakamoto T, Saito Y, Esaki M, Matsuda T. Cost-effectiveness analysis of colorectal cancer screening using colonoscopy, fecal immunochemical test, and risk score. J Gastroenterol Hepatol. 2020 ;35(9):1555-1561.  

    4Lansdorp-Vogelaar I, Goede SL, Bosch LJW, et al. Cost-effectiveness of high-performance biomarker tests vs fecal immunochemical test for noninvasive colorectal cancer screening. Clin Gastroenterol Hepatol. 2018;16(4):504-512.e11.  

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    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Operations for diverticulitis decreased in 2020, but the degree of disease severity increased

    Operations for diverticulitis decreased in 2020, but the degree of disease severity increased

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    Key takeaways 

    • Overutilization of intubation respirators early in the pandemic may have masked signs and symptoms of diverticulitis in COVID-19 patients. 
    • Restricted access to computed tomography scanning and a preference for antibiotics may have been factors in postponing surgery until patients were sicker. 
    • Future research will look at 2021 data to see if care patterns returned to pre-pandemic levels. 

    Newswise — SAN DIEGO: The first year of the COVID pandemic significantly altered how patients and providers treated diverticulitis, causing a significant drop in operations to manage the disease but a corresponding increase in the proportion of more severe cases and the need for emergency surgery, according to results of a nationwide study presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    Rolando H. Rolandelli, MD, FACS, chair of surgery at Morristown Medical Center in Morristown, New Jersey, and professor of surgery at Rutgers New Jersey Medical School, presented a study of 12,514 patients who had a colectomy for diverticulitis in 2018 and 10,869 who had the same procedure in 2020 using the ACS National Surgical Quality Improvement (ACS NSQIP®) database. That decline in 2020 represents a 13.14% decrease in operations for diverticulitis, which is an outpouching of the digestive tract causing painful inflammation or infection. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. It was created by surgeons to help hospitals gauge the quality of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information. 

     “In the first year of the pandemic, 2020, we saw that patients were accessing the healthcare system less frequently for diverticulitis, but those who did were sicker on presentation. As a result, their postoperative outcomes were not as good,” Dr. Rolandelli said. 

    Key findings 

    • Patients were more likely to have emergency surgery for diverticulitis in 2020, with the proportion increasing to 20% of operations from 17.3% (p<0.001). 
    • The proportion of patients with a known abscess or perforation of the gastrointestinal tract also increased, from 50.1 to 54.55% (p<0.001). 
    • The proportion of Black patients increased in 2020, from 7 to 7.7% (p=0.032), which was offset by a decline in the proportion of white patients, from 82.4 to 77.7% (p<0.001). 

    Dr. Rolandelli said the study findings provide two lessons learned.  

    “One, when we limit access to health care, we do it by setting a priority for patients that are potentially at higher risk of progression of their disease, and in the early phase of the COVID pandemic, the priority was cancer patients,” he said. “This situation may have led to physicians  prescribing antibiotics as an alternative to surgery for diverticulitis, which may have caused patients’ disease to progress. By the time of surgery, they were much sicker.”  

    The second lesson learned: A possible overuse of intubation respirators early in the pandemic. “We had patients who basically had been in a coma for weeks and could not express their symptoms of diverticulitis,” he said, which typically include pain in the lower left quadrant of the abdomen and, less frequently, fever and constipation. “We probably saw patients who were developing diverticulitis and we were not realizing it.” 

    Surgeons’ observations  

    Precautions put into place early in the pandemic may have also contributed to the greater severity of diverticulitis cases at that time, Dr. Rolandelli said. Surgeons were informed that the COVID-19 virus could concentrate in the wall of the gastrointestinal tract, including the colon, and that they should exercise caution when using electrocautery to operate on patients with diverticulitis because it could vaporize the virus and cause it to spread. Also, restricted access to computed tomography scans—an important imaging technique for monitoring the growth of diverticular lesions—may have delayed medical treatment or even surgery.  

    Study coauthor Zoltan H. Nemeth, MD, PhD, a research scientist at the department of surgery at Morristown Medical Center and an adjunct assistant professor at Columbia University, New York, explained that a strength of the study was its size and the large population in the ACS NSQIP database. The limitation of such databases is that they do not provide granular data on how individual patients were treated.  

    Next steps 

    Future research will include analyzing 2021 data to see how they compare to 2018 and 2020, according to Dr. Nemeth. 

    “I think it’s clear that, at the beginning of the pandemic in 2020, we were not sure how to approach these patients; it was a learning experience,” Dr. Rolandelli said. “So, when we compare it with 2021, when we had a year of experience and we did not place patients on the respirator as often, we’re going to be able to sort out the differences in terms of how we’re managing the patients and the actual severity of diverticulitis.” 

    Study coauthors are Sara Soliman, BS; Grace C. Chang, DO; and Amanda K. Nemecz, MD, all from Morristown Medical Center.  

    Dr. Rolandelli and Dr. Nemeth have no disclosures to report.   

    Citation: Rolandelli, RH et al. How the Covid-19 Pandemic Affected the Severity and Clinical Presentation of Diverticulitis, Scientific Forum, American College of Surgeons Clinical Congress 2022.  

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    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Marijuana-dependent patients at higher risk for infection after knee or shoulder arthroscopy procedures

    Marijuana-dependent patients at higher risk for infection after knee or shoulder arthroscopy procedures

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    Key takeaways 

    • A higher infection rate found by new research should raise a “red flag” for patients and providers and should be discussed along with other risk factors before an arthroscopic procedure.  
    • Higher rates of deep vein thrombosis (DVT) were also found among these patients, but the study’s analysis determined they were not statistically significant. 
    • The study has identified the need for additional research to better understand the relationship between marijuana dependence and potential postoperative complications. 

    Newswise — SAN DIEGO: Patients who are dependent on marijuana may face higher infection rates following knee and shoulder arthroscopy—a minimally invasive surgery in which a small camera is inserted to diagnose and sometimes treat injury—according to a study presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    Using PearlDiver, a national insurance claims database, researchers from the University of Chicago performed a retrospective study of patients with marijuana dependence who underwent knee or shoulder arthroscopy for the postoperative complications of deep vein thrombosis (DVT), pulmonary embolism (PE), and infection.  

    “Marijuana has been gaining so much popularity, but it’s a risk factor we aren’t really catching,” said lead study author Sarah Bhattacharjee, MD, who conducted the research while she was a medical student at the University of Chicago. Dr. Bhattacharjee is now a surgical resident in orthopaedic and sports medicine at the University of Washington. “The higher infection rate found by this new study should raise a ‘red flag’ for patients and providers and should be discussed along with other risk factors before an arthroscopic procedure.” 

    Although the effect of marijuana use has been studied in pain management and cardiovascular health, few studies have looked at the potential effects of marijuana use by patients who are undergoing surgery. More states are legalizing marijuana, and the size of the cannabis market is predicted to reach $91.5 billion by 2028.* Given that trend, the team of researchers from the University of Chicago set out to determine if marijuana-dependent users face an increased risk of complications following knee or shoulder arthroscopy.  

    “There’s so much information out there on smoking, alcohol, and other substances, but not on marijuana use,” said study coauthor Jason Strelzow, MD, assistant professor of orthopaedic surgery, University of Chicago. “As providers and surgeons, we should be discussing marijuana use with our patients, something that we have traditionally shied away from.” 

    Study details 

    All patients undergoing knee or shoulder arthroscopy were identified retrospectively in PearlDiver. Next, patients who had a diagnostic code for marijuana dependence were also identified within each surgery category; this is a rigid definition requiring patients to three or more criteria, such as using marijuana longer than intended, difficulty in cutting down use, spending a lot of time in obtaining or recovering from marijuana, and high tolerance.  

    The rates of DVT, PE, and infection within 90 days were assessed for all patients. Univariate analyses of marijuana dependence on all outcomes were performed, followed by a multivariate logistic regression analysis controlling for known patient comorbidities (other medical conditions). 

    Key findings 

    • The researchers identified 1,113,944 knee and 747,938 shoulder arthroscopy patients. Out of those 1,861,892 patients, 21,823 patients had a diagnostic code for marijuana dependence.  
    • Within both subgroups, the marijuana dependence cohort experienced increased rates of infection and DVT, while the PE rate stayed the same.  For the shoulder arthroscopy group, the rates of infection increased from 0.7%  to 1.7%, the DVT rate from 0.2% to 0.4%, while PE stayed at 0.2%. In the knee arthroscopy group, the rates of infection increased from 1.1% to 2.6%, the DVT rate rose from 0.2 to 0.3%, and PE stayed at 0.3%.   
    • In the multivariate analyses controlling for a variety of patient risk factors, including tobacco use or a history of diabetes, marijuana dependence was identified as an independent risk factor for infection within both cohorts. In this study, a statistical measure called a p-value (‘p’ stands for probability) was used to determine if the detected relationship was due to chance (p-values of 0.001 or below) or did, in fact, exist (p-values above 0.001). For the knee group, the p-value was 1.85, and for the shoulder group it was 1.65. 

    (Note: The presenting author reported on updated data from the podium during the conference reflecting stable PE rates.) 

    Dr. Strelzow hopes surgeons will use the study results to help inform marijuana-dependent patients about risks, benefits, and available alternatives, such as reducing or eliminating marijuana use six months prior to an arthroscopic procedure. 

    Although the study focused on minimally invasive surgery, Dr. Strelzow said that “we would expect similar or larger effects with more open or invasive procedures.” 

    Future research opportunities 

    The study has identified the need for additional research to better understand the relationship between marijuana dependence and postoperative complications. In addition, given that the study used very rigid criteria for marijuana dependence, there are opportunities for future clinical studies to investigate how various levels of marijuana use impact postoperative complications.  Dr. Strelzow said he plans to study the impact of marijuana dependence on fracture healing. 

    There are no author disclosures to report. 

    ________________________ 

    *Legal Cannabis Market Size Worth $91.5 Billion By 2028 | CAGR: 26.3%: Grand View Research, Inc. press release, July 27, 2021. Assessed at: https://www.grandviewresearch.com/industry-analysis/legal-cannabis-market?utm_source=prnewswire&utm_medium=referral&utm_campaign=HC_27-July-21&utm_term=legal-cannabis-market&utm_content=rd1 (.) 

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    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates a surgeon is a Fellow of the American College of Surgeons.  

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  • New Guidelines for Hamstring Lengthening and Guide Growth Surgery

    New Guidelines for Hamstring Lengthening and Guide Growth Surgery

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    Newswise — For the past several years, Robert Kay, MD, has been part of an international group of experts with an ambitious goal: shaping the future of orthopedic care for ambulatory children with cerebral palsy.

     “There’s so much variation in how surgeons approach these complex patients,” says Dr. Kay, Chief of Orthopedic Surgery and Director of the Jackie and Gene Autry Orthopedic Center at Children’s Hospital Los Angeles. “Our goal is to provide consensus guidelines—not one person’s opinion—to aid surgeons in their clinical decision-making and help ensure the best care for each child.”

     The group, which includes 16 surgeons from 15 leading centers in North America, Europe and Australia, recently published guidelines for two types of surgeries designed to address knee problems in children with cerebral palsy: hamstring surgery and anterior distal femoral hemiepiphysiodesis (also called “guided growth”). Both papers were published in the Journal of Children’s Orthopaedics.

     Dr. Kay — who served as lead author on the hamstring surgery paper and a senior author on the guided growth publication — shares some of the group’s key recommendations.

     Hamstring surgery

    Hamstring lengthening is one of the most common surgeries to address crouch gait, but indications for this procedure have changed in recent years, Dr. Kay says. The panel agreed that:

    • A thorough gait evaluation is key. “You can be fooled just on physical exam in thinking a patient’s hamstrings are tight,” Dr. Kay says. “Computerized hamstring modeling data from a gait lab are really helpful in determining whether a child is a good candidate for this surgery.”
    • Repeat hamstring lengthening has inferior results. A child’s crouch gait can sometimes recur after an initial hamstring lengthening. But the panel agreed that a repeat lengthening is often not successful. For example, Dr. Kay’s team published a paper several years ago showing that while a first hamstring lengthening had a 71% success rate in straightening a child’s knees, that success fell to just 28% with a second procedure.
    • Hamstring lengthening isn’t enough to correct knee flexion contractures. “When contractures are greater than 10 degrees, an isolated hamstring lengthening doesn’t sufficiently address the problem,” Dr. Kay says. “You need to think about doing an osseous procedure around the knee as well.”
    • Hamstring transfer remains controversia Although hamstring transfer surgery offers some theoretical advantages over hamstring lengthening—with the idea that it would lessen post-operative anterior pelvic tilt—the panel concluded that data do not yet show that it has better outcomes than hamstring lengthening.

     “Hamstring transfer is a much bigger, more complicated and painful surgery,” Dr. Kay says. “There may be a role for it down the road, but right now the data don’t support it.”

    • Surgeons should not lengthen lateral hamstrings. The group was unanimous in reporting that they “rarely, if ever” perform isolated lateral hamstring lengthening. There was also consensus that indications for combined medial and lateral hamstring lengthening are very limited in children who walk—those functioning at Gross Motor Function Classification System (GMFCS) levels I-III.
    • It’s important to minimize the number of surgical sessions for a child. Hamstring surgery is rarely performed in isolation. The group recommended simultaneously addressing contractures and bony deformities at other levels, as well as lever-arm dysfunction, in a single-event multilevel surgery.

     Guided growth surgery

    Anterior distal femoral hemiepiphysiodesis was first reported as a method to straighten out knee flexion contractures without cutting into the bone nearly 15 years ago, but it has become much more common in recent years as surgical techniques have evolved. The group agreed that:

    • The surgery is effective in children with a wide range of walking abilities. Guided growth can be indicated in children at GMFCS levels I-IV—from those who walk in all settings without help to those who only walk short distances at home with assistance.

    One advantage is that it’s a low-risk procedure, with small incisions, Dr. Kay adds. Patients are able to start walking the same day as surgery.

    • It’s best for contractures between 10 and 20 degrees. The panel could not reach consensus on whether the procedure should be done for knee flexion contractures outside that range, but members agreed that it is not indicated for those larger than 30 degrees.
    • Percutaneous screws are preferred over anterior plates. This newer technique—which Dr. Kay helped to popularize in recent years—results in far less postoperative pain than the older screw-and-plate constructs.
    • Children should have two years of remaining growth. “The surgery can be a very good option for adolescents who are still growing,” Dr. Kay says. He adds that guided growth is rarely done in children under 10.

     

     What’s next?

    The panel is now working on a consensus paper for foot and ankle surgeries in ambulatory children with cerebral palsy. Long term, the group hopes to do more prospective data collection and potentially create a registry to better track and study outcomes data from these procedures.

     “It’s really important for surgeons to work together to continually optimize care for these patients,” Dr. Kay says. “Improving a child’s ability to walk has a major impact on the quality of life for that child and family. This is something that will affect them for the rest of their lives.”

    About Children’s Hospital Los Angeles  Children’s Hospital Los Angeles is at the forefront of pediatric medicine, offering acclaimed care to children from across the world, the country and the greater Southern California region. Founded in 1901, Children’s Hospital Los Angeles is the largest provider of care for children in Los Angeles County, the No. 1 pediatric hospital in California and the Pacific region, and is consistently ranked in the top 10 in the nation on U.S. News & World Report’s Honor Roll of Best Children’s Hospitals. Clinical expertise spans the pediatric care continuum for newborns to young adults, from everyday preventive medicine to the most medically complex cases. Inclusive, compassionate, child- and family-friendly clinical care is led by physicians who are faculty members of the Keck School of Medicine of USC. Physicians translate the new discoveries, treatments and cures proven through the work of scientists in The Saban Research Institute of Children’s Hospital Los Angeles—among the top 10 children’s hospitals for National Institutes of Health funding—to bring answers to families faster. The hospital also is home to one of the largest training programs for pediatricians in the United States. To learn more, follow us on Facebook, Instagram, LinkedIn, YouTube and Twitter, and visit our blog at CHLA.org/blog. 

     

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  • Is ‘frozen shoulder’ a genetic condition? Study finds links to specific genes

    Is ‘frozen shoulder’ a genetic condition? Study finds links to specific genes

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    Newswise — October 14, 2022 – Frozen shoulder, or adhesive capsulitis, is a common cause of shoulder pain and immobility. New findings point to specific genes associated with an increased risk of this condition, reports The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.

    The risk genes are associated with nearly a sixfold increase in the odds of developing frozen shoulder – a stronger association for most known clinical risk factors, according to the new research by Mark T. Langhans, MD, PhD, of Hospital for Specialty Surgery, New York. The authors believe their findings may lend new insights into the causes, prevention, and treatment of adhesive capsulitis.

    Genome-wide association study finds ‘significant loci’ affecting frozen shoulder risk

    Patients with adhesive capsulitis develop painful and progressive loss of shoulder motion with associated pain. Frozen shoulder is one of the most common shoulder conditions, occurring in up to 10% of people at some time in their lives. Although the exact cause is unclear, frozen shoulder sometimes occurs after an injury, surgery, or other condition that reduces shoulder mobility. Loss of motion results from fibrosis (scarring or thickening) of the capsule around the shoulder joint.

    Certain clinical factors are associated with an increased risk of frozen shoulder, including diabetes, thyroid disease, and smoking. Recent studies have suggested that risk is also higher in people with affected relatives – suggesting a possible genetic predisposition. Dr. Langhans and colleagues performed a genome-wide association study to identify specific genes that might be related to the risk of frozen shoulder.

    Data studied from large British database

    The study used data from a large British database, the UK Biobank, which includes genetic and health data on approximately 500,000 patients. The analysis focused on 2,142 patients with adhesive capsulitis compared to those without this diagnosis. Possible genetic associations were adjusted for other factors, including sex, diabetes, thyroid disease, history of shoulder dislocation, and smoking.

    The study identified three significant loci for frozen shoulder. The strongest association was found for gene variants located at a site called WNT7B. This finding was consistent with previous studies that reported a possible link between WNT7B and frozen shoulder, along with several other orthopaedic-related conditions. Weaker associations were also found for two previously unreported genetic loci located near genes for POU1F1 and MAU2.

    All three associations remained significant after adjustment for other factors. Together, the three variants carried nearly a sixfold increase in the odds of developing frozen shoulder. That was greater than the risk associated with diabetes (about four-fold) or thyroid disease (less than two-fold), and second only to smoking (about 11-fold).

    New insights could lead to a new development

    The findings may lend new insights into the development of adhesive capsulitis. In particular, genes located at WNT7B have been shown to be expressed in bone-forming cells (osteoblasts) and to be involved in regulating fibrosis, along with a wide range of other functions. The two newly reported loci, POU1F1 and MAU2, are involved with cell division, which might lend clues into the cellular mechanism by which frozen shoulder develops.

    The researchers note some key limitations of their analysis, including the need for further studies of genetic associations in groups other than the white, British population that predominates in the UK Biobank.

    Meanwhile, the new study identifies several gene loci with the ability to predict a clinically relevant risk of frozen shoulder. Dr. Langhans and colleagues conclude: “Refining the genetic risk metric and including it in a larger clinical model could allow patients at risk for future adhesive capsulitis to be identified, leading to efforts at prevention, early diagnosis, and ultimately improved outcomes.”

    Click here to read “Genome-Wide Association Study of Adhesive Capsulitis Suggests Significant Genetic Risk Factors“

    DOI: 10.2106/JBJS.21.01407

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    About The Journal of Bone & Joint Surgery

    The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, The Journal publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal.

    About Wolters Kluwer

    Wolters Kluwer (WKL) is a global leader in professional information, software solutions, and services for the clinicians, nurses, accountants, lawyers, and tax, finance, audit, risk, compliance, and regulatory sectors. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with advanced technology and services.

    Wolters Kluwer reported 2021 annual revenues of €4.8 billion. The group serves customers in over 180 countries, maintains operations in over 40 countries, and employs approximately 19,800 people worldwide. The company is headquartered in Alphen aan den Rijn, the Netherlands.

    Wolters Kluwer provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers and students in effective decision-making and outcomes across healthcare. We support clinical effectiveness, learning and research, clinical surveillance and compliance, as well as data solutions. For more information about our solutions, visit https://www.wolterskluwer.com/en/health and follow us on LinkedIn and Twitter @WKHealth.

    For more information, visit www.wolterskluwer.com, follow us on Twitter, Facebook, LinkedIn, and YouTube.

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  • Landmark Clinical Study Finds Aspirin as Effective as Commonly Used Blood Thinner to Prevent Life-Threatening Blood Clots and Death After Fracture Surgery

    Landmark Clinical Study Finds Aspirin as Effective as Commonly Used Blood Thinner to Prevent Life-Threatening Blood Clots and Death After Fracture Surgery

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    Newswise — Patients who have surgery to repair bone fractures typically receive a type of injectable blood thinner, low-molecular-weight heparin, to prevent life-threatening blood clots, but a new clinical trial found that over-the-counter aspirin is just as effective. The findings, presented today at the Orthopaedic Trauma Association (OTA) annual meeting in Tampa, FL, could cause surgeons to change their practice and administer aspirin instead to these patients.

    The multi-center randomized clinical trial of more than 12,000 patients at 21 trauma centers in the U.S. and Canada, is the largest-ever trial in orthopedic trauma patients. The trial was co-led by the Department of Orthopaedics at the University of Maryland School of Medicine (UMSOM) and the Major Extremity Trauma Research Consortium (METRC) based at the Johns Hopkins Bloomberg School of Public Health.

    “We expect our findings from this large-scale trial to have an important impact on clinical practice, and potentially even change the standard of care,” said the study’s principal investigator Robert V. O’Toole, MD, the Hansjörg Wyss Medical Foundation Endowed Professor in Orthopaedic Trauma at UMSOM and head of the school’s Division of Orthopaedic Traumatology. “Orthopaedic trauma patients are commonly prescribed the blood thinner low-molecular-weight heparin to prevent blood clots for weeks following surgery. Not only does the medication need to be injected, it can also be quite expensive compared to aspirin.”

    Blood clots cause as many as 100,000 deaths in the U.S. each year, according to the U.S. Centers for Disease Control (CDC). Patients who experience fractures that require surgery – an estimated 1 million people in the U.S. annually – are at increased risk of developing blood clots in the veins, including a fatal pulmonary embolism, which is a clot in the lung. Current guidelines recommend prescribing low-molecular-weight heparin (enoxaparin), although research in total joint replacement surgery suggested a potential benefit of aspirin as a less-expensive, widely available option.

    Dr. O’Toole, who is also Chief of Orthopaedics at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center (UMMC), presented the results of the landmark clinical trial at the OTA annual meeting. The $12 million study was funded by the Patient-Centered Outcomes Research Institute (PCORI), (PCS-1511-32745), an independent, nonprofit organization that finances research to help patients and clinicians make better-informed healthcare decisions.

    The study enrolled 12,211 patients with leg or arm fractures that necessitated surgery or pelvic fractures regardless of the specific treatment. Half were randomly assigned to receive 30 mg of injectable low-molecular-weight heparin twice daily. The other half received 81 mg of aspirin twice daily. The follow-up period after surgery was 90 days.

    The main finding of the study was that aspirin was “noninferior,” or no worse, than low-molecular-weight heparin in preventing death from any cause – 47 patients in the aspirin group died compared with 45 patients in the heparin group. Secondary outcomes noted no differences in non-fatal pulmonary embolism. The incidence of bleeding complications and all other safety outcomes was similar in both groups.  Of all the outcomes studied, the one potential difference noted was fewer blood clots in the legs in the low-molecular-weight heparin group. This relatively small difference was driven by clots lower in the leg, which are of unclear clinical importance.

    “With data from more than 12,000 patients, this study provides clear evidence that aspirin is a viable option for preventing blood clots in the lung and death in patients who require surgery for orthopaedic trauma,” said Andrew Pollak, MD, the James Lawrence Kernan Professor and Chair of the Department of Orthopedics at UMSOM and Senior Vice President and Chief Clinical Officer for the 11-hospital University of Maryland Medical System (UMMS).

    The trial was called PREVENTion of CLots in Orthopaedic Trauma, or PREVENT CLOT. Patients enrolled in the trial were treated at the R Adams Cowley Shock Trauma Center at UMMC and 20 other trauma centers in 15 other states and two in Canada. Recruitment started in April 2017 and continued through 2021. Deborah Stein, MD, MPH, Professor of Surgery at UMSOM and Director of Adult Critical Care Services at UMMC, and Renan Castillo, PhD, an Associate Professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, are co-principal investigators.

    “This exciting trial, the largest ever conducted in orthopedic trauma patients, provides important guidance to surgeons in helping to prevent potentially fatal blood clots after fracture surgery by using a medication that is both inexpensive and easy to administer,” said Mark T. Gladwin, MD, Vice President for Medical Affairs, University of Maryland, Baltimore, and the John Z. and Akiko K. Bowers Distinguished Professor and Dean, University of Maryland School of Medicine.

     

    About the University of Maryland School of Medicine

    Now in its third century, the University of Maryland School of Medicine was chartered in 1807 as the first public medical school in the United States. It continues today as one of the fastest growing, top-tier biomedical research enterprises in the world — with 46 academic departments, centers, institutes, and programs, and a faculty of more than 3,000 physicians, scientists, and allied health professionals, including members of the National Academy of Medicine and the National Academy of Sciences, and a distinguished two-time winner of the Albert E. Lasker Award in Medical Research. With an operating budget of more than $1.3 billion, the School of Medicine works closely in partnership with the University of Maryland Medical Center and Medical System to provide research-intensive, academic, and clinically based care for nearly 2 million patients each year. The School of Medicine has nearly $600 million in extramural funding, with most of its academic departments highly ranked among all medical schools in the nation in research funding. As one of the seven professional schools that make up the University of Maryland, Baltimore campus, the School of Medicine has a total population of nearly 9,000 faculty and staff, including 2,500 students, trainees, residents, and fellows. The combined School of Medicine and Medical System (“University of Maryland Medicine”) has an annual budget of over $6 billion and an economic impact of nearly $20 billion on the state and local community. The School of Medicine, which ranks as the 8th highest among public medical schools in research productivity (according to the Association of American Medical Colleges profile), is an innovator in translational medicine, with 606 active patents and 52 start-up companies. In the latest U.S. News & World Report ranking of the Best Medical Schools, published in 2021, the UM School of Medicine is ranked #9 among the 92 public medical schools in the U.S., and in the top 15 percent (#27) of all 192 public and private U.S. medical schools. The School of Medicine works locally, nationally, and globally, with research and treatment facilities in 36 countries around the world. Visit medschool.umaryland.edu

     

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  • ACS comments on European study on colonoscopies published in New England Journal of Medicine

    ACS comments on European study on colonoscopies published in New England Journal of Medicine

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    Newswise — CHICAGO (October 11, 2022): The American College of Surgeons (ACS) is aware of a European study examining colonoscopy in Sweden, Poland, Norway, and the Netherlands, “Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death,” published this week in the New England Journal of Medicine1 that may seem to call into question the effectiveness of colonoscopy screening.

    Although the ACS recognizes global discrepancies in cancer screening recommendations across countries, the ACS remains committed to supporting U.S. evidence-based recommendations and practices based on decades of research, including the use of colonoscopy to screen for colorectal cancer.

    “As an evidence-based and educational organization of surgeons, it is clear that patient outcomes are vastly improved when cancer is detected early,” said ACS Executive Director & CEO, Patricia L. Turner, MD, MBA, FACS. “The value and importance of colonoscopies in preventing and detecting colorectal cancer cannot be overstated, and current U.S. guidelines are based on decades of research in the United States showing that routine screenings with colonoscopy can save lives.”

    “We recognize that this study is generating a lot of attention and could have the effect of discouraging some from getting life-saving colonoscopy screenings. We firmly stand behind the science that has unequivocally demonstrated the benefits of these screenings,” said Heidi Nelson, MD, FACS, Medical Director of the ACS Cancer Programs. As the Emeritus Fred C. Andersen Professor for the Mayo Foundation and consultant for Mayo Clinic’s division of colon and rectal surgery, Dr. Nelson is internationally renowned for her research in the field of colon and rectal cancer. “Significant work has gone on to optimize the reliability and accuracy of the colonoscopy test, both in terms of optimizing bowel preparations performed in advance of the procedure and the specialized training of the clinicians who perform the procedure. The evidence and data are abundantly clear that screenings with colonoscopies save lives. The bottom line is that people should continue to follow their doctors’ recommendations on colonoscopy screening.”

    Excluding skin cancers, colorectal cancer is the third most common cancer diagnosed in the United States, according to the American Cancer Society.2 Since the 1990s, national guidelines have supported the use of colonoscopies to screen for colorectal cancer.3 The procedure – in which a tube-like instrument with a light and video camera is inserted into the rectum to visualize abnormalities – can not only detect early cancers but can also prevent colorectal cancer through the removal of polyps, which can take 10-15 years to turn into cancer. 

    Moreover, colonoscopy has been recognized as an effective and reliable preventive health practice by the federal government. In 2000, the law expanded Medicare coverage to beneficiaries who were not considered high risk for colon cancer.4 Today, the American Cancer Society currently recommends that people at average risk of colorectal cancer start regular screening at age 45 through either a colonoscopy or a stool-based test.

    —

    1 Bretthauer M, Løberg M, Wieszczy P, et al. Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death,  New Engl J Med, 2022 Oct 9. doi:10.1056/NEJMoa2208375

    2 American Cancer Society Guideline for Colorectal Cancer Screening: https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html

    3 Trends in Screening for Colorectal Cancer -United States, 1997 and 1999: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5009a2.htm

    4 Moore KJ, Medicare Expands Preventive Screening Benefits, Fam Pract Mang. 2001; 8(6):16: https://www.aafp.org/pubs/fpm/issues/2001/0600/p16.html

     

    # # #  

      

    About the American College of Surgeons  

    The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.   

     

     

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  • NREF Honor Your Mentor Funds Exceeds $7 Million in Pledges

    NREF Honor Your Mentor Funds Exceeds $7 Million in Pledges

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    Newswise — The Neurosurgery Research and Education Foundation’s (NREF) Honor Your Mentor (HYM) Funds started in 2014 with a modest six funds and total pledges of $177,195 from 37 donors. Today, NREF is excited to announce that the program has climbed to an impressive 70 funds with total pledges of $7,067,324.84 from 2,459 donors.

    “As the chair of NREF, I want to personally thank two of our most committed leaders, Jon H. Robertson, MD, FAANS, FACS, and Regis W. Haid, Jr, MD, FAANS, for their ingenuity in creating the HYM funds,” states Michael Groff, NREF chair. “What started in 2014 with six funds has grown beyond everyone’s wildest expectations. The HYM program, and the NREF itself, has matured into a juggernaut that supports every aspect of the Neurosurgical mission. I am excited to share with our supporters that we have just crossed the $7 million threshold for HYM. Thanks to the foresight of those that came before our future is brighter than ever. Thank you for your past support and please consider making a contribution to honor the mentor of your choice.”

    To date, HYM Funds have provided more than $575,000 in funding for important neurosurgical projects and awards. The funds support leadership endeavors, research projects, educational initiatives and outcomes studies. All neurosurgical subspecialties are represented, as well as various organizations and institutions.

    Each fund has a specific purpose and donations fund a chosen research or educational endeavor in the honoree’s name.

    ###

    About the NREF The Neurosurgery Research & Education Foundation (NREF) is a not-for-profit 501(c)(3) organization created in 1980 by the American Association of Neurological Surgeons (AANS) to support research and education efforts that enhance and confirm the critical role neurosurgeons play in improving lives.

    The NREF is dedicated to providing education to neurosurgeons at all stages of their careers, as well as funding research into new and existing neurosurgical treatments, in order to identify links between best practices and improved outcomes in patient care. Through voluntary public donations, corporate support, and donations from allied groups, the NREF supports endeavors that impact the lives of those suffering from epilepsy, stroke, brain tumors, spinal disorders, sports-related head injuries, lower back pain and Parkinson’s disease.

    For more information about NREF, please visit www.nref.org.

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  • Study: Novel Imaging Technique Reveals Excellent Biologic Fixation in Cementless Knee Replacement

    Study: Novel Imaging Technique Reveals Excellent Biologic Fixation in Cementless Knee Replacement

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    Newswise — Cementless knee replacement, an alternative approach to the traditional surgery in which bone cement is used, is gaining interest among orthopedic surgeons. Using a novel MRI technique, researchers at Hospital for Special Surgery (HSS) found that a cementless implant demonstrated excellent biologic fixation, and even improved fixation of implant components in some areas in the joint, compared to the standard cemented implant.

    HSS hip and knee surgeon Geoffrey Westrich, MD, and colleagues in the HSS Radiology Department used an advanced imaging technique known as “multi-acquisition variable-resonance image combination selective MRI” to assess fixation in patients who had a cementless knee replacement compared to those whose implant was affixed with bone cement.

    “The purpose of our study was to quantify and compare the fixation of uncemented versus cemented knee replacement components,” said Dr. Westrich, lead investigator. “At an average patient follow-up of 16 months, our study demonstrated robust fixation of the cementless knee replacement components, with results comparable to the cemented total knee replacements. And while there was no clinically significant difference regarding overall fixation in the knee, there were some component areas in which cementless fixation appeared to be superior.” The study was published in the October edition of the journal Arthroplasty Today.  

    The HSS researchers performed MRIs in 20 patients who had a cementless knee replacement. A matched control group of 20 patients with a cemented knee replacement was also evaluated. The images were reviewed by a fellowship-trained musculoskeletal radiologist specializing in the interpretation of joint replacement MRI, including more than 20 years of experience in assessing bony fixation of knee replacement components.

    In a traditional knee replacement, implant components are secured in the joint using bone cement. It’s a tried-and-true technique that has worked well for decades. But eventually, over time, the cement may start to loosen from the bone and/or the implant. This loosening is the leading cause of revision surgery, in which a patient needs a second knee replacement.

    “With the cementless prosthesis, the components are press fit into place for biologic fixation, which basically means that the bone will grow into the implant,” explains Dr. Westrich, who believes a well-designed cementless implant will make loosening over time less likely. This could enable a total knee replacement to last much longer, a particular concern for younger patients.

    “Overall, traditional knee replacement offers excellent outcomes and longevity,” he says. “However, younger patients generally put more demands on their joint, causing more wear and tear and potential loosening. The cemented knee implant used in a traditional joint replacement usually lasts 15 to 20 years.”

    Cementless implants have been used successfully in total hip replacement surgery for many years. It has been much more challenging to develop a cementless prosthesis that would work well in the knee because of its particular anatomy, Dr. Westrich explains.

    “Early generation cementless implants had numerous design flaws resulting in loosening and poor survivorship compared to cemented knee replacements,” he says. “More contemporary cementless knee components such as those used in our study utilize highly porous surfaces to promote biologic fixation of the prosthesis. This should improve outcomes.”

    Candidates for the cementless procedure are generally patients under age 70 with good bone quality to promote biologic fixation. In addition to younger patients, Dr. Westrich notes that the cementless implant may prove to be a good option for very overweight patients who tend to put more stress on their joint replacement.

    “While our study found that early fixation of cementless total knee components are comparable, if not superior, to cemented total knee replacement, further study with a larger number of patients over a lengthier time period is needed to assess long-term durability and fixation.”

    Disclosure: Research support received from Stryker Corporation. 

     

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  • Study casts doubt on routine use of anesthesiologists in cataract surgery

    Study casts doubt on routine use of anesthesiologists in cataract surgery

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    Newswise — Ophthalmologists may be able to safely cut back on having anesthesiologists or nurse anesthetists routinely at bedside during cataract surgery, which accounts for more than two million surgeries per year in the U.S., according to a study publishing Oct. 3 in JAMA Internal Medicine. 

    A team of researchers from UC San Francisco examined Medicare claims for 36,652 patients who had cataract surgery in 2017 and found the use of anesthesia care was substantially higher for cataract surgery when compared to patients undergoing other elective, low-risk outpatient procedures—such as cardiac catheterization or screening colonoscopy. However, they found that these patients experienced fewer systemic complications—such as myocardial infarction or stroke—than did patients undergoing the other low-risk procedures.  These results held true even in cases where anesthesia experts were not present for the cataract surgery, suggesting that for many cataract patients, it may be reasonable to consider doing the procedure without routine anesthesia support.

    “It’s important to note we only looked at systemic complications and not ophthalmologic outcomes from the procedure,” noted senior study author Catherine Chen, MD, MPH, UCSF associate professor in  Anesthesia and Perioperative Care and researcher at the Philip R. Lee Institute for Health Policy Studies. “We are evaluating those next, but it would be premature to say we should change practice now based on this study. Hopefully we can get a conversation going, though.” 

    Some type of anesthetic and possibly sedation is needed for cataract surgery, Chen noted, but the question is who should be present for administration and intraoperative monitoring of these patients. In the past, cataract surgery carried a much higher risk of complications, which helps explain the historic and legacy use of anesthesiologists and/or certified registered nurse anesthetists (CRNA). 

     “The risk of the procedure itself used to require general anesthesia with paralysis and inpatient admission. Over time, ophthalmologists improved their technique so it [cataract surgery] is much safer and can be done on an outpatient basis,” said Chen. “Often the patient just needs a topical anesthetic such as numbing drops in the eyeball, and, at UCSF anyway, a little fentanyl and midazolam, which are agents a sedation nurse can administer safely.”

    A Question of Resources

    The study found that, for cataract surgery, 90% of U.S. Medicare patients have an anesthesia provider at the bedside compared to a range of <1% to 70% at bedside for other low-risk elective procedures. In contrast, fewer cataract surgery patients experienced systemic complications within seven days (7.7%) than patients undergoing other low-risk procedures (range, 13% to 52%).  

    Approximately 6% of ophthalmologists never used anesthesia providers, 77% always used anesthesia providers, and 17% used them for only a subset of patients. Patients of those ophthalmologists who never used anesthesia providers had a 7.4% rate of systemic complications. 

    There is no specific guidance from professional associations on whether to include an anesthesia expert during cataract surgery, but other countries do not routinely use them, to no ill effect, Chen noted. 

    With U.S. anesthesiologists being asked to staff an increasing number of non-OR procedures, such as endoscopic or interventional radiology procedures where patients tend to be much sicker and the procedure potentially more invasive, there often aren’t enough of these specialists go around, Chen said. 

    “Add to this a general shortage of anesthesiologists since COVID, and it’s clear we need to ensure staff resources are used efficiently,” said Chen.

    In an upcoming study, Chen and her colleagues will look at both systemic and ophthalmologic outcomes stratified by whether patients received care from an anesthesia provider during cataract surgery. While the current study used a sample of 5% of Medicare claims, the upcoming study will use 20% of claims. 

    “It’s certainly possible that by having an anesthesiologist there, the patients are calmer and possibly less likely to move, and so the ophthalmologic outcomes could be better—so we are working on those studies now,” Chen said. “Where I think where we could end up, when the results are in, is that instead of automatically defaulting to include an anesthesiologist, we stratify patients by risk so that their level of sedation and anesthesia support matches their likelihood of complications.”

    Co-authors and funding: Please see paper for additional co-authors and funding disclosures.

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    University of California, San Francisco (UCSF)

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  • October 2022 Issue of Neurosurgical Focus: Video: “Flow Diversion for Cerebral Aneurysms”

    October 2022 Issue of Neurosurgical Focus: Video: “Flow Diversion for Cerebral Aneurysms”

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    October 2022 Issue of Neurosurgical Focus: Video: “Flow Diversion for Cerebral Aneurysms”

    Rolling Meadows, IL (October 1, 2022). The October issue of Neurosurgical Focus (Vol. 7, No. 2 [https://thejns.org/video/view/journals/neurosurg-focus-video/7/2/neurosurg-focus-video.7.issue-2.xml]) presents 8 articles discussing flow diversion for cerebral aneurysms.

    Topic Editors: Peter T. Kan, Elad I. Levy, Felipe C. Albuquerque, and Mandy Jo Binning     

    Noting that “flow diversion represents a major advancement in the treatment of cerebral aneurysms,” in this issue of Neurosurgical Focus: Video, the Topic Editors present videos representing a “spectrum of cases” involving flow diversion for a variety of aneurysm treatment experiences.

     

    Contents of the October issue: 

    • “Introduction. Flow diversion for cerebral aneurysms” by Peter T. Kan et al.
    • “Flow diversion for cerebral aneurysms” by Joseph A. Carnevale et al.
    • “Challenging access during flow diversion treatment of a giant cavernous ICA aneurysm” by Visish M. Srinivasan et al.
    • “FRED flow diversion with LVIS protection of large posterior communicating artery aneurysm: the “FRELVIS” technique” by Steven B. Housley et al.
    • “Treatment of an acutely ruptured complex fusiform middle cerebral artery aneurysm with flow diverting stenting and adjunctive coil embolization” by Guilherme Barros and Michael R. Levitt
    • “Treatment of a ruptured blister aneurysm of the left internal carotid artery with telescoping Pipeline Flex embolization devices with Shield Technology” by Karol P. Budohoski et al.
    • “Combined deconstructive and reconstructive treatment of a giant vertebrobasilar fenestration aneurysm” by Lorenzo Rinaldo et al.
    • “Woven EndoBridge embolization in the retreatment of basilar apex aneurysm” by Jae Eun Lee et al.
    • “Flow diversion of a dissecting PICA aneurysm” by Tyler Lazaro et al.

     Please join us in viewing the videos in this month’s issue of Neurosurgical Focus: Video.

     ***

    Embargoed Article Access and Author/Expert Interviews: Contact JNSPG Director of Publications Gillian Shasby at [email protected] for advance access and to arrange interviews with the authors and external experts who can provide context for this research.

     ###

    The global leader for cutting-edge neurosurgery research for more than 75 years, the Journal of Neurosurgery (www.thejns.org) is the official journal of the American Association of Neurological Surgeons (AANS) representing over 12,000 members worldwide (www.AANS.org).

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    Journal of Neurosurgery

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  • Oncoplasty: Breast Cancer Surgery with Cosmetic Results

    Oncoplasty: Breast Cancer Surgery with Cosmetic Results

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    Newswise — New Brunswick, N.J., October 1, 2022 – In recent decades, advances in breast cancer surgery have dramatically changed the treatment of the disease. It’s no longer just the removal of the whole breast (mastectomy), or taking out the tumor (lumpectomy). Now, women have more options made possible by the dynamic field of oncoplastic surgery, which is a combination of cancer surgery with traditional plastic surgery techniques to remove breast cancers and simultaneously leave the remaining breast as intact as possible. Shicha Kumar, MD, FACS, surgical oncologist in the Stacy Goldstein Breast Cancer Center at Rutgers Cancer Institute of New Jersey, the state’s leading cancer center and only National Cancer Institute-Designated Comprehensive Cancer Center together with RWJBarnabas Health; and assistant professor of surgery at Rutgers Robert Wood Johnson Medical School, shares more.

    Cancer is Removed, Breasts are Saved

    Oncoplastic surgical techniques involve careful planning of skin and breast tissue removal, and incorporate many different approaches. For some, it may be an incision around the nipple, in the armpit area, under the breast – to both improve appearance and decrease lumpectomy defects. For other patients, a more complex approach may be appropriate involving reshaping the entire breast gland after removing a large amount of breast tissue and repositioning the nipple. This may be accompanied by more advanced techniques such as replacing breast volume with tissue from other parts of the body and even operating on the non-affected breast with a reduction procedure to achieve the same look on both sides. 

    An Unexpected Silver Lining

    Many patients are surprised to learn that breast cancer surgery can improve the cosmetic appearance of their breasts. Oncoplastic surgical techniques provide many positive benefits for women healing from both the physical and emotional journey of breast cancer. Research has shown that these techniques improve quality of life, sense of wellbeing and gives patients confidence in their body image, knowing they can preserve their natural breasts without leaving the breast distorted or asymmetric.

    When to Consider this Surgery  

    The decision-making regarding the selection of patients for oncoplastic techniques includes many factors, such as tumor size, tumor location, breast size and shape, the density of glandular tissue, the presence of other chronic illness, smoking, need for additional cancer treatment, and patient preference. At Rutgers Cancer Institute and RWJBarnabas Health, our experts have experience in various oncoplastic techniques for lumpectomy and work closely with other surgical oncologists and plastic surgeons throughout the health system to achieve desirable results.  This collective experience translates into the best possible outcomes for our patients.

    Learn more at rwjbh.org/mammo.

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    Rutgers Cancer Institute of New Jersey

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  • Low long-term risk of breast cancer recurrence after nipple-sparing mastectomy

    Low long-term risk of breast cancer recurrence after nipple-sparing mastectomy

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    Newswise — September 29, 2022 – Nipple-sparing mastectomy (NSM) – an increasingly popular option for women undergoing treatment for breast cancer – not only achieves good cosmetic outcomes, but also low long-term risk of recurrent breast cancer, reports a study in the October issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS). The journal is published in the Lippincott portfolio by Wolters Kluwer.

    Ten years after NSM, the rate of recurrent breast cancer is only 3%, according to the new research, led by ASPS Member Surgeon Mihye Choi, MD, of the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. The researchers write, “Nipple-sparing mastectomy remains a viable option in the appropriately indicated patient with regards to long-term cancer recurrence.”

    Not just improved cosmetic outcomes – NSM provides good long-term cancer control

    In the NSM technique, the surgeon preserves the nipple and surrounding tissues for use in immediate breast reconstruction. Compared to conventional mastectomy, NSM allows for a more natural-looking reconstruction, leading to higher patient satisfaction. However, there is little information about the long-term risk of recurrent breast cancer after NSM.

    Dr. Choi and colleagues evaluated breast cancer outcomes in 120 patients undergoing NSM for breast cancer treatment. The analysis included a total of 126 therapeutic NSM procedures. The analysis excluded prophylactic (preventive) NSM procedures to reduce the risk of breast cancer in women at high genetic risk.

    At a median follow-up of 10 years after NSM, the analysis showed low recurrent cancer risks: 3.33% per patient and 3.17% per reconstructed breast. Of the four patients with recurrent cancer, two had local recurrences (breast only) and two had cancer spread to other locations (locoregional recurrence).

    Recurrence risk was higher for women who had cancer involving the lymph nodes. However, on analysis adjusting for other factors, there were no demographic, surgical, or tumor-related variables that predicted the risk of recurrent breast cancer.

    The researchers point out some key limitations of their findings – including selection bias related to the characteristics of patients likely to be considered good candidates for NSM. Most of the patients in the study had early-stage breast cancers: stage 1 in about 45% and stage 0 in 34%.

    The finding of good long-term cancer control is especially important in light of the growing use of NSM and immediate reconstruction for women with breast cancer. “Patients with NSMs have had low locoregional recurrence rates in a retrospective review of patients with a median follow-up of 10-years,” Dr. Choi and colleagues conclude. They add: “Despite low rates of recurrence, close surveillance remains important to continually assess for long-term safety of NSM.”

    Click here to read “Long-Term Cancer Recurrence Rates following Nipple-Sparing Mastectomy: A 10-Year Follow-Up Study“

    DOI: 10.1097/PRS.0000000000009495

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    About Plastic and Reconstructive Surgery

    For over 75 years, Plastic and Reconstructive Surgery® (http://www.prsjournal.com/) has been the one consistently excellent reference for every specialist who uses plastic surgery techniques or works in conjunction with a plastic surgeon. The official journal of the American Society of Plastic Surgeons, Plastic and Reconstructive Surgery® brings subscribers up-to-the-minute reports on the latest techniques and follow-up for all areas of plastic and reconstructive surgery, including breast reconstruction, experimental studies, maxillofacial reconstruction, hand and microsurgery, burn repair and cosmetic surgery, as well as news on medico-legal issues.

    About ASPS

    The American Society of Plastic Surgeons is the largest organization of board-certified plastic surgeons in the world. Representing more than 7,000 physician members, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises more than 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada.

    About Wolters Kluwer

    Wolters Kluwer (WKL) is a global leader in professional information, software solutions, and services for the clinicians, nurses, accountants, lawyers, and tax, finance, audit, risk, compliance, and regulatory sectors. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with advanced technology and services.

    Wolters Kluwer reported 2021 annual revenues of €4.8 billion. The group serves customers in over 180 countries, maintains operations in over 40 countries, and employs approximately 19,800 people worldwide. The company is headquartered in Alphen aan den Rijn, the Netherlands.

    Wolters Kluwer provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers and students in effective decision-making and outcomes across healthcare. We support clinical effectiveness, learning and research, clinical surveillance and compliance, as well as data solutions. For more information about our solutions, visit https://www.wolterskluwer.com/en/health and follow us on LinkedIn and Twitter @WKHealth.

    For more information, visit www.wolterskluwer.com, follow us on Twitter, Facebook, LinkedIn, and YouTube.

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    Wolters Kluwer Health: Lippincott

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