The Bulletin http://bulletin.facs.org of the American College of Surgeons Thu, 21 May 2015 20:05:07 +0000 en-US hourly 1 http://wordpress.org/?v=4.1.5 Looking forward – May 2015 http://bulletin.facs.org/2015/05/looking-forward-may-2015/ http://bulletin.facs.org/2015/05/looking-forward-may-2015/#comments Fri, 01 May 2015 05:59:02 +0000 http://bulletin.facs.org/?p=12985 In this month’s column, Dr. Hoyt highlights A History of Surgery at Cook County Hospital, a new book edited by ACS fellows that describes the hospital’s impact on surgical care and its ties with the College.

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The Beaux Arts facade of the hospital.

The Beaux Arts facade of the hospital.

An 1890 amputation (with bare hands) in Ward 9. At the time, there were no designated operating rooms.

An 1890 amputation (with bare hands) in Ward 9. At the time, there were no designated operating rooms.

A 1950s surgical ward.

A 1950s surgical ward.

Dr. Murphy, wearing a special head lamp, performing a tendon repair of the hand.

Dr. Murphy, wearing a special head lamp, performing a tendon repair of the hand.

A Friday night in the trauma unit.

A Friday night in the trauma unit.

David B. Hoyt

David B. Hoyt, MD, FACS

Few medical and surgical institutions have the legendary history associated with Cook County Hospital (now Stroger Hospital of Cook County) in Chicago, IL. Many Fellows of the American College of Surgeons (ACS), particularly trauma surgeons, can recall doing at least one rotation through Cook County Hospital (CCH), and most Americans are somewhat familiar with the institution as the model for the hospital featured in the long-running television series ER and for a cameo appearance in the movie The Fugitive.

Many Past-Presidents and other leaders of the American College of Surgeons (ACS)—including John B. Murphy, the Mayo brothers, Albert Ochsner, Allen B. Kanavel, Olga Jonasson, Robert J. Lowe, Herand Abcarian, and L.D. Britt (all MD, FACS)—trained, taught, or practiced at or have been in some way affiliated with CCH. Details about the impact that the hospital has had on all surgical specialties and its strong ties with the ACS are chronicled in a new book, A History of Surgery at Cook County Hospital, edited by ACS Fellows Patrick D. Guinan, Kenneth J. Printen, James L. Stone, and James S. T. Yao—each of whom trained and practiced at CCH. Some snippets of the institution’s fascinating history as documented in the book follow.

Service and education

The first iteration of CCH was set up in the Fort Dearborn trading post in 1803 to provide care to U.S. Army soldiers. The first surgeon at Fort Dearborn was William C. Smith, and the first recorded surgical procedure was a bilateral leg amputation performed by Elijah Dewey Harmon, MD, in 1832. That same year, Cook County was incorporated by the State of Illinois, and the hospital undertook its continuing commitment to serving the sick, injured, and medically indigent citizens of the county. From 1876 to 2002, the main building was located at 1825 W. Harrison. Over the years, it grew into what once was the largest general hospital in the world, with 4,500 beds, and one of the nation’s most highly regarded training centers.

General surgery at CCH originated with Christian Fenger, MD, a pathologist and the first chair of surgery at Northwestern University. Dr. Fenger trained ACS founders, including Dr. Murphy and William and Charles Mayo. At one point, all six Chicago-area medical schools—Rush, Northwestern, University of Illinois, Loyola, University of Chicago, and Chicago Medical School—had attending surgeons and surgical residents teaching and training at CCH with no financial compensation. CCH started as an intern hospital and gradually became a residents hospital in the late 1930s, receiving approval from the recently formed Accreditation Council for Graduate Medical Education in 1939.

As some of you may know, a common practice in the early days of surgical education was to demonstrate an operation in an amphitheater setting. Chicago’s first surgical amphitheater was built at CCH. As an attending surgeon, Dr. Murphy began conducting his well-known surgical clinics in the amphitheater on Friday mornings. Karl Meyer, MD, FACS, and Raymond McNealy, MD, FACS, went on to use the amphitheater for similar purposes, drawing crowds of physicians to observe their wet clinics.

CCH also was one of the first institutions to use night surgeons. This position was designed to hone the skills of the attending surgeon and to develop the surgical judgment of surgical residents. Robert T. Vaughn, MD, FACS, a general surgeon at St. Luke’s Hospital, was the assistant warden for night emergencies at CCH for 33 years (1917­­­­­­­­­­­­–1950), providing clinical instruction and care and making extensive contributions to the surgical literature on topics ranging from osteomyelitis of the sternum to retrograde amnesia following skull fracture.

In addition to being a leading surgical training ground, CCH was the launching pad of many medical and surgical services that have benefitted patients around the world. For example, Bernard Fantus, MD, founded the first blood bank at CCH in 1937. Also in the 1930s, Dr. Kanavel and Sumner L. Koch, MD, FACS, established a burn surgical service at CCH. Renamed in Dr. Koch’s honor in the 1960s, the burn center would prove remarkably successful in improving the survival rates and quality of life for burn victims. In addition, Drs. Kanavel and Koch played an influential role in fostering the growth of a world-class hand surgery service.

Leaders at the CCH and of the ACS also made invaluable contributions to the development of the surgical specialties, including cardiothoracic, pediatric, neurological, vascular, urological, orthopaedic, plastic, otolaryngological, oral and maxillofacial, ophthalmic, and colon-rectal surgery.

A new age

The 1960s was a period of enormous political, social, and scientific change. It also was a time when health care and medical education were becoming more intensely scrutinized. All of these factors had a significant effect on inner-city teaching hospitals like CCH.

Richard J. Freeark, MD, FACS, was appointed chair of the department of surgery at CCH in 1963 and medical superintendent in 1968. Dr. Freeark laid the groundwork for revitalizing the resources of the hospital to promote quality care and to establish a superior postgraduate training program in general surgery and the surgical specialties. He succeeded in many ways.

With respect to surgical training, Dr. Freeark made two important moves: he established a two-month rotation with surgeons at the Lahey Clinic, Burlington, MA; and he recruited renowned surgeons George Block and Don Ferguson of the University of Chicago and Otto Trippel and John J. Bergan of Northwestern (all MD, FACS) to join the volunteer attending staff.

On the clinical side, Dr. Freeark and Robert J. Baker, MD, FACS, oversaw the development of the nation’s first official dedicated trauma center—the CCH trauma unit—in 1966. The CCH trauma unit became the conceptual model for trauma systems planning, patient care, and training throughout the nation. The trauma unit also housed a computerized trauma registry developed in conjunction with the University of Illinois, Chicago. As the value of trauma registries continued to rise, John Fildes, MD, FACS, and Richard J. Fantus, MD, FACS (Bernard Fantus’s grandson), collaborated to establish the ACS National Trauma Data Bank® in 1989.

The socioeconomic turmoil affecting the city in the late 1960s and early 1970s and decades of neglect took their toll on the institution. Dr. Freeark resigned as medical superintendent in 1970. Gerald Moss, MD, FACS, from the University of Illinois took over the department of surgery in 1972 and led a significant revitalization of the surgery program. He rebuilt the freestanding residency program in general surgery by recruiting outstanding graduates of the program to lead the divisions of general and pediatric surgery. He also retained outstanding residents in general surgery and the surgical specialties to train residents and serve as attendings. For example, in 1972 he appointed Dr. Abcarian, who began his training as an intern at CCH in 1966, to serve as program director of the colon-rectal surgery residency and section chief of colon and rectal surgery at CCH—positions he would hold for 23 years of tremendous growth and advancement.

Dr. Moss was succeeded by Olga Jonasson, MD, FACS, a skillful academic, general, and transplant surgeon. As chair of surgery at CCH, Dr. Jonasson led the integration of the general surgery residency program with the University of Illinois program. A controversial move at the time, it ultimately improved surgical training at CCH. Dr. Jonasson resigned from CCH in 1986 to serve as the Zollinger Professor and Chair, department of surgery, Ohio State University, Columbus. She ended her career at the ACS headquarters as Director of Surgical Education and Research.

Her successor at CCH was Hernan M. Reyes, MD, FACS, chair of the CCH division of pediatric surgery. Under his leadership, the surgery departments were restructured, new leadership was appointed, and, to attract more competent attending staff, salaries were upgraded. Clinical improvements included better patient follow-up, reinstitution of the cardiac surgery program, recruitment of a full-time director of breast surgery service, replacement of an outdated cancer registry with an electronic record-keeping system, establishment of the Hektoen Institute for Medical Research focused on advancement in surgical technology, advancements in laparoscopic surgery, and improved survival rates among critical care patients.

A must read

The book ends with historical vignettes, and the print edition also contains photos collected from CCH alumni and the ACS Archives. This column has barely skimmed the surface of all the information covered in this book and hardly touched upon the contributions of ACS Fellows associated with CCH.

The editors are to be commended for their efforts to compile a comprehensive, compelling, and loving reflection on an institution to which the surgical profession and patients around the world are deeply indebted. I would encourage anyone who is interested in learning more about the history of our profession and the ACS to read the book.


If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.

 

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Strategies for sustainability: Going green in the OR http://bulletin.facs.org/2015/05/strategies-for-sustainability-going-green-in-the-or/ http://bulletin.facs.org/2015/05/strategies-for-sustainability-going-green-in-the-or/#comments Fri, 01 May 2015 05:58:34 +0000 http://bulletin.facs.org/?p=12988 Effective green OR strategies reduce operating cost, eliminate waste, and improve environmental sustainability. This article highlights practical solutions for promoting the kind of culture change necessary to achieve long-lasting green OR initiatives.

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Dr. Paluch with trash from a single case, all to be disposed of as biohazardous waste.

Dr. Paluch with trash from a single case, all to be disposed of as biohazardous waste.

“It’s interesting because people tend to come out of the woodwork as soon as you start to talk about green OR initiatives openly....Other hospital systems and organizations may have this kind of program already in place, with people in place whose jobs are focused on these issues, and you might not even be aware of it. Go and see if something like this already exists.” —Dr. Klaristenfeld

“It’s interesting because people tend to come out of the woodwork as soon as you start to talk about green OR initiatives openly....Other hospital systems and organizations may have this kind of program already in place, with people in place whose jobs are focused on these issues, and you might not even be aware of it. Go and see if something like this already exists.” —Dr. Klaristenfeld

“Ours has been a grassroots movement; it was not led by administration.... Peer-to-peer communication means there is a representative from each group on the green team—surgeons, nurses, surgical technicians, physician assistants, custodians, and so on. If I need to get a message out to the surgeons, I talk to them as the surgeon representative on the green OR team.” —Dr. Andrade

“Ours has been a grassroots movement; it was not led by administration.... Peer-to-peer communication means there is a representative from each group on the green team—surgeons, nurses, surgical technicians, physician assistants, custodians, and so on. If I need to get a message out to the surgeons, I talk to them as the surgeon representative on the green OR team.” —Dr. Andrade

Disposable items removed from a single direct laryngoscopy kit. This kit is used approximately 40 time per month.

Disposable items removed from a single direct laryngoscopy kit. This kit is used approximately 40 time per month.

Digital scale display of the total weight in grams (equivalent to 22 oz) of disposable items removed from a single direct laryngoscopy kit.

Digital scale display of the total weight in grams (equivalent to 22 oz) of disposable items removed from a single direct laryngoscopy kit.

“When we began our program, we decided it had to be cost-neutral.... And very quickly we were able to demonstrate with a few small, grassroots initiatives that not only were we able to remain cost-neutral, but we actually saved money. Saving money and reducing our carbon footprint energized the committee and captured the administrators’ attention.” —Dr. Heniford

“When we began our program, we decided it had to be cost-neutral.... And very quickly we were able to demonstrate with a few small, grassroots initiatives that not only were we able to remain cost-neutral, but we actually saved money. Saving money and reducing our carbon footprint energized the committee and captured the administrators’ attention.” —Dr. Heniford

Dr. Heniford’s green team members package recycled surgical supplies for medical mission trips to developing countries

Dr. Heniford’s green team members package recycled surgical supplies for medical mission trips to developing countries.

Dr. Heniford participating in a 2010 Operation Hernia medical mission trip in Mongolia. The surgeons used the recycled surgical supplies donated by the CMC OR.

Dr. Heniford participating in a 2010 Operation Hernia medical mission trip in Mongolia. The surgeons used the recycled surgical supplies donated by the CMC OR.

Dr. Heniford participating in a 2010 Operation Hernia medical mission trip in Mongolia. The surgeons used the recycled surgical supplies donated by the CMC OR.

Dr. Heniford participating in a 2010 Operation Hernia medical mission trip in Mongolia. The surgeons used the recycled surgical supplies donated by the CMC OR.

Going green, particularly in the operating room (OR), is a meaningful goal for many environmentally conscious surgeons, but for budget-wary hospital administrators, the decision to adopt more sustainable practices is often about the other green—money. Current research suggests sustainable OR initiatives do, in fact, reduce operating cost while eliminating waste and improving environmental sustainability.

According to Greening Health Care: How Hospitals Can Heal the Planet, U.S. hospitals produce more than 2.3 million tons of waste each year, with an average of 26 pounds of waste per staffed bed in the course of a single day.1 When the environmental ramifications of these numbers are considered along with the impact on health care expenditures, the validity of cost-cutting environmental stewardship programs becomes increasingly apparent. Whether it’s the red bag waste reduction initiative of the Carolinas Medical Center (CMC), Charlotte, NC, which resulted in a $50,000 per year savings, or the streamlining of surgical kits at the University of Minnesota Medical Center, Fairview, which has yielded $104,000 in savings annually—these programs have demonstrated that they protect both the environment and the institutions’ bottom line.2,3

In this article, surgeon leaders discuss effective green OR strategies, offer guidelines for reporting program outcomes, and highlight practical solutions for promoting the kind of culture change necessary to achieve long-lasting results.

Single-use devices and surgical kits

“The first step toward [creating] a green OR is to observe what is going on around you and to find out how you are contributing to your environmental footprint,” said Tom Paluch, MD, a general surgeon with the Kaiser Foundation Medical Center, San Diego, CA, and co-presenter of The Environmentally Responsible Surgical Practice Panel Session at the 2014 Clinical Congress. “Reducing disposable instrumentation is the single biggest way a surgeon can have a positive impact on the environment. We eliminated single-use devices (SUDs) for laparoscopy, and we went from consuming $300,000 worth of equipment a year to virtually nothing—and that’s just in one hospital here in San Diego,” said Dr. Paluch.

Each year, Kaiser Permanente reduces medical waste by recycling and safely reusing SUDs, according to Dr. Paluch. Recycling SUDs—which is conducted in strict accordance with U.S. Food and Drug Administration (FDA) regulations—reduces purchasing and overall waste disposal costs.4

In addition to recycling SUDs, Kaiser Permanente has partnered with MedShare, a not-for-profit organization dedicated to repurposing unused, unexpired medical equipment that previously ended up in landfills. MedShare is one organization that redistributes these supplies to clinics and hospitals in the developing world.4 Approximately 2 million pounds of recoverable medical supplies can be found each year in large, metropolitan U.S. academic medical centers. Collectively, these materials hold a potential value of at least $15 million per year.5

Another way surgeons can contribute to the sustainability of their health care institutions is by working with colleagues to standardize operative packs and trays, according to Daniel Klaristenfeld, MD, FACS, FASCRS, a colorectal surgeon, Kaiser Permanente, San Diego, and moderator of the 2014 Clinical Congress Panel Session. “For common procedures like gallbladder surgery or hernia repair, we walk into a case and instead of having every available instrument open and on the table, they are available but not opened, which saves time and money,” he said. All opened instruments, regardless of whether they are used in a procedure, must be sterilized again and repackaged.

Streamlining surgical kits or packs has been a priority for Rafael Andrade, MD, FACS, a general thoracic surgeon at the University of Minnesota Medical Center, since 2009. Dr. Andrade, along with Lynn Thelen, RN, launched a grassroots OR Green Team to explore the feasibility of reducing waste at their hospital. After soliciting input from colleagues, they examined 38 different types of OR packs to determine which devices, such as plastic basins, catheters, and syringes, were unused and then instructed their product vendor to remove the items from the packs.3 For example, a pack designed for inserting an intravenous port in chemotherapy patients was whittled down from 44 devices to 27, and disposable gowns and linens were replaced with reusable items. Overall, this initiative resulted in a reduction of one pound of trash and $50 in supply cost savings per procedure.3

“Most surgeons don’t know what exactly is in the kit when they enter the OR. They simply want to come in and start operating and not waste time trying to get [supplies that are] not available,” said Dr. Andrade. “We explained to the surgeons that items that are never used are going to be removed [from the kits] and that items that are sometimes used can be on hold in the room, but not included in the kit so they don’t get wasted every single time.” Dr. Andrade said in-person meetings with hospital and surgeon leaders were key in dealing with resistance and quickly led to acceptance and support of the initiative. “All upfront work—getting buy-in from the surgeons—is done in person,” he said.

Red bag initiative

At CMC, red bags in the OR and intensive care units (ICUs) are designated for biohazardous waste. According to B. Todd Heniford, MD, FACS, chief, division of gastrointestinal and minimally invasive surgery, CMC, it costs 10 times as much per pound to dispose of these materials than other waste, primarily due to the cost of transporting and incinerating red bag waste, not to mention the effect of the toxic release of dioxin on the environment as a result of this processing.

“What we found was that staff was throwing essentially everything that touched a patient into a red bag, so it was simply a matter of educating our teammates about the difference between biohazardous materials and general waste, which typically goes to a landfill. While a landfill is not a great option, it is certainly better than incineration,” explained Dr. Heniford, co-author of “The green operating room: Simple changes to reduce cost and our carbon footprint,” published in a 2013 issue of The American Surgeon.2

“We also found that in the ICUs the biggest trash cans held red bags, so people threw everything in there,” Dr. Heniford said. “We changed the trash cans—I say ‘we,’ but it was the institution’s custodial staff who suggested changing the size of the trash cans. They made the red bag trash can the smallest one in the room, and they also purposely placed these cans in the corner of the room so that you had to walk a few feet to dispose of an item there,” he added. Staff members now have to make more of an effort to dispose of an item in a red bag, which serves as a reminder to only place heavily soiled materials in these receptacles.

Dr. Heniford said his institution observed a 75 percent reduction in red bag waste, with an estimated savings of more than $50,000 a year. The red bag initiative is a product of the CMC’s Green Operating Room Committee (GORC), formed in 2008 with members from surgical, nursing, anesthesia, and OR staff, and environmental services.2

Educating staff members on proper disposal of biohazardous waste versus general waste, rather than underscoring policy mandates and regulations, is the best way to ensure team member buy-in, according to Dr. Andrade. At the University of Minnesota Medical Center, staff members are now required to take an online course on proper waste disposal as part of their annual education requirements.6

Environmentally preferred purchasing

Surgical kit reduction, waste elimination, water conservation, and other green OR initiatives essentially start, in some form or another, with purchasing. Environmentally preferred purchasing (EPP), according to Dr. Paluch, can be defined as the “purchase of products and services whose environmental impact have been considered and found to be less damaging to the environment and human health when compared [with] competing products and services.”7 These items could include reusable surgical instruments, environmentally safe/reduced product packaging, and even general cleansers and solvents formulated specifically for a reduced impact on the environment.8 In a sense, EPP can be considered “preventive medicine” that promotes a healthy environment through products that are green friendly.8

According to Vanessa Lochner, director of EPP for Kaiser Permanente, buying green occurs in three distinct phases:9

  • Pre-sourcing: This step involves the work prior to a sourcing event—researching what various vendors have to offer. For example, it might entail sending a chemical disclosure questionnaire to suppliers or reviewing a product category for reduced packaging opportunities.
  • Sourcing: In this phase, also known as procurement, hospital administrators and green OR teams define their requirements so that suppliers in the marketplace may bid on goods and services.
  • Implementation: This step is the execution phase of a project or initiative that produces a positive environmental outcome—one that is trackable with metrics.

Surgeon leaders can have an impact on a facility’s purchasing decisions, Dr. Paluch suggests, particularly at the sourcing phase when product requirements are addressed with vendors. Surgeons and OR green teams can also contribute to EPP initiatives by assisting in product assessments, tracking purchasing decisions, and monitoring cost-benefit analysis of these products and services. Perhaps most importantly, surgeons who are champions of EPP can help develop stakeholder and colleague engagement in these purchasing decisions by promoting the positive effects on the environment.

In 2014, Johnson & Johnson, the pharmaceutical and manufacturing company, partnered with Harris Poll to measure the importance of sustainability issues among global health care professionals, including surgeons, OR nurses, and hospital executives in the U.S. and five other countries.10 More than half (54 percent) of respondents to the study report that their hospitals currently incorporate sustainability into purchasing decisions, and 80 percent anticipate that will be the case within two years. More than 300 health care professionals participated in the 2014 survey, either online (289) or by phone (40).10

According to the study, health care professionals also agree it makes good financial sense for hospitals to go green, both in the U.S. (79 percent) and globally (69 percent). In fact, 67 percent of domestic and 60 percent of international respondents report a growing commitment to sustainability from top hospital management.10

“The biggest reason for hospitals to be involved in green initiatives is cost savings—but it is a nice benefit to be able to say to the public that you are environmental [stewards],” said Dr. Paluch. “When we say we are here for your health—we mean it on every level. Green OR programs are a great way to show commitment to the overall well-being of a patient—not just giving them medicine, but providing an environment in which they will be safer, cleaner, and healthier.”

“By being green, we sacrifice nothing,” added Dr. Heniford. “Being green demonstrates our responsibility to not only to our patients but to our communities.”

Culture change

Surgeon leaders can accelerate the culture change needed to encourage and sustain green practices at their institutions. To ensure the longevity and success of these programs, surgeon leaders should develop a collaborative support network throughout the organization and provide hospital executives and staff members with measurable results.

“The raison d’etre for a hospital is not to be an environmentally savvy organization; it is to take care of the patient,” said Dr. Paluch. “How do we best do that? By providing quality care, but also by being environmental stewards. To make these kinds of changes, it is as simple as going to the administration; and, yes, it is as difficult as going to administration. It’s like turning a battleship with a canoe paddle—it’s not an easy thing to do. However, these initiatives tend to catch on—one, because it’s smart, and two, because they save money. That is what gets people interested because it’s measurable. If you can’t measure it, you can’t manage it.”

Providing hospital administrators with tangible results was the justification behind the first green initiative—water conservation—led by the GORC team at CMC. According to Dr. Heniford, the scrub cycles of 100 consecutive physicians, nurses, residents, and technicians were observed to determine how much time they spent scrubbing before an operation. In all but two cases, water ran nonstop while staff members scrubbed, whether their hands were under the water or not. And frequently, the water was left running even when no one was at the sink. To minimize this problem, OR sinks were outfitted with flow meters, and the GORC estimated daily, weekly, and yearly use.

“We demonstrated to OR staff that we could save real [amounts of] water by making a conscious effort to conserve it,” said Dr. Heniford. “At that point, only 20 percent of the surgeons, nurses, and scrub techs used waterless scrub prior to surgery, and when we surveyed staff, the reason was purely based on tradition. There must be something soothing about hearing the water run prior to an operation. Once we convinced staff to use an alcohol-based waterless scrub—which is as safe or safer than water scrub—we have [had]an estimated savings of 2.7 million liters of water per year in the ORs alone, in just our hospital.” Tethered to this water-saving initiative were additional green-friendly cost savings from a decrease in washing and processing towels and lower sewer-use fees.2

“When we began our program, we decided it had to be cost-neutral,” said Dr. Heniford. “And very quickly we were able to demonstrate with a few small, grassroots initiatives that not only were we able to remain cost-neutral, but we actually saved money. Saving money and reducing our carbon footprint energized the committee and captured the administrators’ attention.”

In addition to offering hospital administrators tangible, measurable results, such as cost savings and waste-reduction outcomes, Dr. Andrade and his colleagues were able to help achieve a culture change throughout his organization through peer-to-peer communication. “Ours has been a grassroots movement; it was not led by [the] administration,” revealed Dr. Andrade. “Peer-to-peer communication means there is a representative from each group on the green team—surgeons, nurses, surgical technicians, physician assistants, custodians, and so on. If I need to get a message out to the surgeons, I talk to them as the surgeon representative on the green OR team. If someone needs to communicate something to the nurses, then the nurse on the team conveys that information. We’ve emphasized this model from the very beginning because it’s where you get more bang for your buck. It’s not a surgeon imposing a message or request on nurses, or a surgical tech trying to sell something to the surgeons. Peer-to-peer communication is the best way to engage staff members in green initiatives,” said Dr. Andrade.

“It’s interesting because people tend to come out of the woodwork as soon as you start to talk about green OR initiatives openly,” said Dr. Klaristenfeld. “Other hospital systems and organizations may have this kind of program already in place, with people in place whose jobs are focused on these issues, and you might not even be aware of it. Go and see if something like this already exists.”

Transparency regarding the sustainability efforts of a green OR team is also key to maintaining staff engagement. Reporting green team outcomes and comparing results from previous years or even results from different departments within the same facility can help generate renewed interest in a water use reduction program or a red bag initiative.

“As a surgeon, being green is not going to be at the forefront of my daily existence, so the only way to keep it a priority is to keep putting it in front of me and my peers,” Dr. Paluch noted. His institution has a regular reporting cycle that details the team’s accomplishments on a monthly or bimonthly basis. “When we remind surgeons that the same patient care can be administered with environmental savvy or stewardship, we’re going to sign on to this—but we need reminders because this is not our primary focus.”

“One of the most important things we were able to do is keep score,” added Dr. Heniford. “Keeping score energizes people because they see that they can make a difference.”

Conclusion

Demonstrating a return on the investment of time and resources is essential when launching a sustainability program and is likely the most convincing way to foster a culture change throughout an organization. Surgeons are natural leaders who foster collaboration both inside and outside the OR and are essential to the long-term success of a green OR initiative. Leading by example, surgeons can play a significant role in developing an interdisciplinary green team, encouraging reprocessing of single-use surgical devices, establishing a sustainable waste management program, and advocating for green-friendly purchasing practices.


References

  1. Kaiser Permanente. Excerpts from Greening Healthcare: How Hospitals Can Heal the Planet. August 12, 2014. Available at: http://share.kaiserpermanente.org/article/excerpts-from-greening-health-care-how-hospitals-can-heal-the-planet/. Accessed February 18, 2015.
  2. Wormer BA, Augenstein VA, Carpenter CL, et al. The green operating room: Simple changes to reduce cost and our carbon footprint. Am Surg. 2013;79(7):666-671.
  3. Chen I. In a world of throwaways, making a dent in medical waste. The New York Times. July 5, 2010. Available at: www.nytimes.com/2010/07/06/health/06waste.html?pagewanted=all. Accessed February 18, 2015.
  4. Kaiser Permanente. Reducing, re-using, and recycling to eliminate waste. May 30, 2014. Available at: http://share.kaiserpermanente.org/wp-content/uploads/2014/06/WasteReduction-factsheet_20141.pdf. Accessed February 18, 2015.
  5. American College of Surgeons. An estimated two million pounds of unused medical supplies may be recoverable in U.S. operating rooms each year [press release]. October 2014. Available at: www.facs.org/media/press-releases/2014/wan1027. Accessed February 23, 2015.
  6. Hankel A. Greening the OR. Surgical Products. July 5, 2011. Available at: www.surgicalproductsmag.com/articles/2011/07/%E2%80%98greening%E2%80%99-or. Accessed February 18, 2015.
  7. Paluch T. A Skeptic’s Epiphany: Environmentalism in Surgical Product Procurement. Presented at 2014 American College of Surgeons Clinical Congress; October 28, 2014; San Francisco, CA.
  8. Practice Greenhealth. Environmentally preferable purchasing. Available at: https://practicegreenhealth.org/topics/epp. Accessed February 18, 2015.
  9. Lochner V, Hayter S, Johnson R. Developing and Managing a Sustainable Portfolio Mix of EPP Projects. Presented at CleanMed2014; June 2-4, 2014; Cleveland, OH.
  10. Advancing sustainability in health care [news release]. Johnson & Johnson. October 1, 2014. Available at: www.csrwire.com/press_releases/37402-Globally-Hospitals-are-Driving-Toward-Greener-Purchasing-Decisions-Greater-than-50-Increase-Expected-in-Next-Two-Years. Accessed February 18, 2015.

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PreOp program: Can we achieve a “trickle-up” effect? http://bulletin.facs.org/2015/05/preop-program-can-we-achieve-a-trickle-up-effect/ http://bulletin.facs.org/2015/05/preop-program-can-we-achieve-a-trickle-up-effect/#comments Fri, 01 May 2015 05:57:22 +0000 http://bulletin.facs.org/?p=12994 This article describes the PreOp program—a preclinical surgical exposure initiative—and how it successfully offers increased surgical exposure to first-year medical students by providing preliminary data from an ongoing longitudinal study of this program.

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The authors, from left: Ms. Lazow, Ms. Venn, and Dr. Dakin.

The authors, from left: Ms. Lazow, Ms. Venn, and Dr. Dakin.

Few moments really have the power to change an individual, but most people can point to at least one or two life-altering events. For the lead author, Rachael A. Venn, one of these experiences occurred when she was in her early 20s and was given the opportunity to scrub-in on an operation. Up to this point, becoming a surgeon had never crossed her mind. But there she stood, holding a retractor as if it were the most important task she would ever perform. And in that moment, it was. Words cannot adequately describe the intrigue and awe Ms. Venn felt at not only seeing, but touching the uterus, ovaries, and fallopian tubes, each with a gleam and texture that elude the diagrammatic representation of a medical textbook.

By the time the last suture was placed, Ms. Venn knew a few things: she loved the operating room (OR), she had to be that close to a patient again, and she would go to medical school. What she did not know was that, based on the current structure of medical education, if she wanted to re-enter the OR, she would either have to wait several years until her surgery clerkship, or she would have to create the opportunity for it to happen sooner.

PreOp—a preclinical surgical exposure program established through a joint effort at Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY—was the opportunity that Ms. Venn and co-author Stefanie P. Lazow created in their first year of medical school. This program explores the potential impact of preclinical surgical exposure on medical students’ specialty interest and their surgical confidence and competency. This article describes the PreOp model and how it successfully offers increased surgical exposure to first-year medical students, providing preliminary data from an ongoing longitudinal study of this program.

Generating enthusiasm

Exposure to surgery and surgical education has historically been neglected in the preclinical years of medical school. In light of ongoing concerns about the prospect of surgeon shortages in the near future and growing reports of reduced resident competency, the preclinical years may be an opportune time to pique medical students’ interest in surgery and guide them toward surgical careers. Intensive surgical exposure at this time may contribute to a “trickle-up” effect, providing students with early training that will not only stimulate surgical interest, but also serve as a foundation for increased competency at subsequent stages of their careers.

Most U.S. medical schools follow a two-plus-two pattern, in which the first two years of the curriculum are classroom-based, and the last two are clinical. While there has been a recent push to incorporate more skills-based learning and patient interaction into the preclinical years, early, structured surgical exposure is still lacking.

This dearth of early hands-on experience is especially problematic given projected physician shortages. The U.S. Department of Health and Human Services recently published a report indicating that by the year 2020, the field of general surgery will experience a shortage of more than 20,000 surgeons, meaning demand for their services will far exceed the supply. This projection is based not only on the changing demographic of an aging population, but also on a concomitant decrease in the number of practicing general surgeons.1

These changes emphasize a need to better understand what drives medical student interest in pursuing surgical training. Studies of clerkship students indicate that mentorship and hands-on participation in the OR are two factors that influence students’ desires to pursue surgical careers.2 Several medical school programs have attempted to provide both components to first-and second-year medical students. These institutions have found that participants in these programs had increased enthusiasm about surgery in comparison with matched control students who lacked such exposure.3,4 However, little long-term follow-up research has been conducted to assess whether this increased preclinical exposure ultimately affects specialty preferences or match outcomes.

Further complicating an undersupply of surgeons is the current climate of resident education. Based on examination scores and clinical performance, work-hour restrictions have been associated with a decline in patient outcomes and resident education.5 The same studies described previously also found that preclinical students who experienced more intensive surgical exposure had consistently higher self-reported confidence ratings when asked about basic surgical skills.3,4 Using confidence as a proxy for competence, which has yet to be directly measured, these results suggest that targeting interested students for training earlier in their medical education may enhance their preparedness as third-year clerks, then as residents, and ultimately as young attending surgeons—a sort of trickle-up effect.

Introducing PreOp

With these possibilities in mind, the authors set out to design a program that offers medical students mentored and active participation in the OR, starting from their first month of medical school to the time of their residency match. The purpose of this study is not only to show that there is a place for intensive surgical exposure in the preclinical years, but also to share a successful model that can be readily implemented in medical schools throughout the country. Examining the factors that influence student satisfaction, career interest, and confidence and competency in preclinical exposure programs may help guide the early stages of training for the next generation of surgeons.

Study design

The PreOp pilot program ran from September 2013 to June 2014 as a collaborative effort between Weill Cornell Medical College and New York-Presbyterian Hospital. Participants included 10 attending surgeons, who served as mentors, and 10 first-year medical students. (One of the 10 selected students decided to terminate his participation in PreOp and was not replaced.)

The mentors were recruited across a number of specialties—including cardiothoracic, general, neurologic, and plastic surgery, as well as otorhinolaryngology, and urologynd were selected based on their interest in medical education and their willingness to engage preclinical students in the OR.

Students from the class of 2017 were invited to apply and were accepted the summer before matriculating. Admittance to the program was based upon a qualitative review of a student’s personal statement and his or her curriculum vitae by Gregory F. Dakin, MD, FACS, the surgical faculty sponsor and a co-author of this article, and Charles L. Bardes, MD, associate dean of admissions at Weill Cornell Medical College. Each month, students rotated with one of the mentors, spending one to five days in the OR and/or clinic. A parallel skills component, which consisted of four skills workshops and two lectures, was designed to increase both student confidence and competence with basic surgical skills.

As part of a study approved by the institutional review board at Weill Cornell Medical College, PreOp program students completed a monthly survey detailing their involvement with and impression of that month’s rotation. Nine matched control first-year medical students were recruited based on a demonstrated interest in surgery, either by signing up to participate in Weill Cornell’s already established but less intensive surgical interest group or by applying to PreOp without being accepted.

Both PreOp and control students completed baseline and end-of-year surveys to gauge the extent to which surgical exposure influenced their specialty preferences. Over the next three years, these two cohorts will be followed longitudinally and resurveyed to assess whether participation in PreOp affects the following: specialty preference and ultimate match outcome, self-reported preparation before and after the third-year surgical clerkship, and competency during the third-year surgical clerkship as measured by the professor’s evaluations and grades. Thus, PreOp is a prospective cohort study that will span all four years of medical school.

Preliminary results

Data collection and statistical analysis included only the nine PreOp students who completed all 10 months of rotations. Results from the pilot year indicate that the PreOp program successfully provided students with increased hands-on surgical exposure. All PreOp students scrubbed in for at least one operation during the year, and the PreOp students had the opportunity to scrub in on more than half of the total rotations (52.6 percent). These numbers are in stark contrast to the control group, in which only one student had the opportunity to scrub in throughout the year, despite the fact that the control students observed more than 43 procedures. Moreover, all PreOp students were able to suture intraoperatively during at least one rotation, while none of the students in the control group had a similar opportunity.

Preliminary statistical analysis was performed to assess factors that increased student satisfaction with each individual rotation. This assessment showed that increased hands-on participation in the OR through scrubbing in was related to increased student satisfaction and higher rotation evaluations (p<0.001), supporting previously reported findings of the importance of hands-on participation in developing student surgical interest.3

After establishing a substantial difference in surgical exposure between the PreOp and control students and determining which factors influenced student satisfaction on a per rotation basis, students were asked whether 10-month participation in the PreOp program affected career interest overall. All PreOp and control students initially expressed an interest in exploring surgery at the start of the year. The students also were asked to anticipate how likely they would be to apply to match into a surgical field as fourth-year students. PreOp students reported increased surgical interest at the end of the year as compared with the beginning, with seven (77.8 percent) reporting being very likely to apply to match into surgery at the end, compared with four (44.4 percent) at the start of the program. In contrast, only two (22.2 percent) of the control students reported being very likely to apply to match into surgery at the end of the year—a number that remained unchanged from the start of the year.

Ready for implementation

PreOp was designed to provide students with attending mentorship and hands-on participation in the OR starting from their first month of medical school. Its successful implementation supports the idea that such programs can be readily formed and can offer markedly increased surgical exposure in comparison with conventional shadowing.

Preliminary data indicate that similar programs should promote hands-on participation to maximize student satisfaction. The authors’ goal is to determine whether surgical exposure through preclinical programs like PreOp can enhance both surgical interest and competency. This study is unique in its longitudinal nature, and the authors intend to continue following PreOp students to assess surgical competency and confidence throughout their four years of medical school. They anticipate that follow-up studies will show that preclinical students represent an ideal target population for career recruitment and earlier training, potentially providing a solution to the dual problem of physician shortages and inadequate resident preparation.

Disclosure

The PreOp program is funded by an education grant from W.L. Gore & Associates, Inc.


References

  1. Harris S. Physician shortage spreads across specialty lines. Association of American Medical Colleges. Available at: www.aamc.org/newsroom/reporter/oct10/152090/physician_shortage_spreads_across_specialty_lines.html. Accessed July 3, 2014.
  2. Berman L, Rosenthal MS, Curry L, Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: Role models, mentoring, and engagement in the operating room. J Am Coll Surg. 2008;207(6):793-800.
  3. Drolet BC, Sangisetty S, Mulvaney PM, Ryder BA, Cioffi WG. A mentorship-based preclinical elective increases exposure, confidence, and interest in surgery. Am J Surg. 2014;207(2):179-186.
  4. Sammann A, Tendick F, Ward D, Zaid H, O’Sullivan P, Ascher N. A surgical skills elective to expose preclinical medical students to surgery. J Surg Res. 2007;142(2):287-294.
  5. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: Impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041-1053.

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Surgeons develop visionary plan to bring corneal transplants to developing countries http://bulletin.facs.org/2015/05/surgeons-develop-visionary-plan-to-bring-corneal-transplants-to-developing-countries/ http://bulletin.facs.org/2015/05/surgeons-develop-visionary-plan-to-bring-corneal-transplants-to-developing-countries/#comments Fri, 01 May 2015 05:56:07 +0000 http://bulletin.facs.org/?p=12999 Key features of a successful corneal transplant system in underserved countries are highlighted in this article, including the private-public partnership model that can be useful in offsetting costs, building surgical capacity, and establishing the infrastructure to support an eye bank.

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Dr. Waller (top left) looks on as Dr. Jain (a local eye surgeon, at microscope) and a local nurse assistant (left) transplant a cornea. Drs. Jindal and Patel observe

Dr. Waller (top left) looks on as Dr. Jain (a local eye surgeon, at microscope) and a local nurse assistant (left) transplant a cornea. Drs. Jindal and Patel observe

Many developing nations now have health care providers that offer specialty care. For example, kidney transplantation was practically nonexistent in low- and middle-income countries and end-stage renal disease was considered a death sentence until recent years.1-3 Since 2008, a renal transplant program launched in Guyana by Rahul M. Jindal, MD, PhD, MBA, FACS (coauthor of this article), and colleagues has carried out 26 living kidney transplants, numerous peritoneal dialysis catheter placements, and vascular access procedures for hemodialysis.1 Dr. Jindal’s team has delivered lectures and held press conferences to raise local physician and patient awareness of the transplant program. They also have initiated a public health project to train selected individuals living in each village (average education of 12th grade and above) in basic clinical skills, such as recording blood pressure and blood sugar measurements, and noting lifestyle modifications, including dietary practices, and hygiene levels, which will allow the student team to act as primary health care workers.1

More recently, the team established a successful, sustainable corneal transplant program in Guyana. To launch this program, Dr. Jindal and his colleagues used a private-public partnership (PPP) model, working with government agencies to attain sponsorship to help offset costs, build surgical capacity, establish an infrastructure for an eye bank, identify appropriate patients, and provide reliable follow-up. This article describes some of the key features of a successful corneal transplantation system, such as the establishment of accredited eye banks; the factors that influence the success of a corneal transplant program; how the authors successfully implemented the PPP model; and the lessons learned in developing this program.

Need in developing countries

Although the prevalence of blindness is greatest in developing countries, the availability of corneal transplant surgery and donor tissue is lowest in such places. As this disparity has become increasingly apparent to health officials, establishing eye banks in low-income countries has become a priority. Despite some efforts by various governmental and nongovernmental organizations, the supply of corneas falls short of the demand.4 Keratoprosthesis, use of an artificial cornea, may be an alternative to corneal transplant in a small percentage of the cases.5

Corneal opacities are cited as the third most common cause of blindness and represent 7 percent to 25 percent of all causes of blindness worldwide.6-8 Corneal blindness is more common in developing countries and is underreported, thus making it difficult to estimate its true prevalence.7 The epidemiology of corneal blindness varies by region and age and is dependent on the ocular diseases that are endemic to the geographic location. Corneal blindness is a leading cause of permanent visual impairment, as scarring and vascularization of the cornea cannot be reversed.9

Most causes of corneal blindness in developing countries are either treatable or preventable.10 According to a 2005 study, the diseases that most frequently lead to corneal blindness include trachoma, onchocerciasis, leprosy, ophthalmia neonatorum, and xerophthalmia.8 In a study of 12,899 participants in India, the most common causes leading to corneal blindness included pterygium (34.5 percent), ocular trauma (22.3 percent), and infectious keratitis (14.9 percent).11 Infectious, traumatic, and autoimmune corneal diseases were the three leading causes of corneal blindness in China.12 A study from Tanzania reported corneal infections, vitamin A deficiency, and measles as the top three causes of bilateral corneal blindness.13

The transplant team with a pre-corneal transplant patient. From left: Dr. Jain; the first corneal transplant recipient in Guyana; Drs. Jindal, Waller, and Patel; and Mr. Subraj.

The transplant team with a pre-corneal transplant patient. From left: Dr. Jain; the first corneal transplant recipient in Guyana; Drs. Jindal, Waller, and Patel; and Mr. Subraj.

In South America, common causes leading to blindness include pterygium, ocular trauma, and trachoma, among others. Ocular trauma constituted 30 percent to 40 percent of all ophthalmological emergencies. Trachoma is another condition that leads to corneal blindness. Some reports from Latin America cite relatively small numbers of infections, which may indicate the problem is being underdiagnosed.14 In Mexico, a report from 2007 showed up to 42 percent of children in certain locations are affected by the condition.15 In Brazil, prevalence varied from 2.2 percent in major cities to 50 percent in remote areas, although more recent reports suggest decreasing prevalence.16-18

Eye bank requirements and procedures

The key to any successful transplant program is rigorous organ banking. Eye banks in the U.S. must be certified by the Eye Bank Association of America (EBAA), which was established in 1961 to serve as the national accrediting organization for eye banks in the U.S., and the U.S. Food and Drug Administration. Eye banks in Central and South America, as well as the Caribbean, should be certified by the Pan American Association of Eye Banks, also known as Associação Pan-Americana de Bancos de Olhos (APABO).

Essential resources for corneal transplants

  • Documentation of cleanliness
  • Access to sterile surgical instrument packs, gloves, gown, mask
  • Sufficient outlets and back-up power
  • Solutions: Sterile saline for irrigation
  • Recording refrigerator: 24/7/365, 2–8o C
  • Sink, counter space, laminar flow hood, access to slit lamp biomicroscope
  • Endothelial cell counter
  • Tissue: Labeled and segregated into four distinct and separate groups: in process, quarantine, research, ready for release
  • Optisol GS or McCarey-Kaufman medium (the two types of storage media for the harvested cornea that include gentamicin and streptomycin)
  • Penlight, slit lamp, specular microscope, optical coherence tomography to evaluate the eye
  • Trephines, trephine handle, donor corneal punch

To attain certification, eye banks must have a medical director—an ophthalmologist with expertise in cornea transplantation—and an administrative director on staff. The medical director is responsible for ensuring the application of medical standards to all aspects of the system, educating health care personnel, releasing and distributing corneal tissue, and overseeing the waiting list. The administrative director, on the other hand, is responsible for public awareness and quality control and interacts with accreditation agencies, including the APABO, the ministry of health in the host nation, and the national association of ophthalmology.

Eye bank staff also must include at least one technician who is certified by APABO. The technician’s responsibilities include obtaining the consent of the family for corneal donation, conducting a medical history review, examining the donor, evaluating the eye and determining appropriateness of tissue for transplantation, retrieving tissue by following eye bank standard operating procedures (SOPs), and obtaining serologic testing of the donor. The essential materials needed for a bank to operate appropriately are described in the sidebar.

To operate an independent eye bank, SOPs, including medical standards to protect the tissue recipient and the technician, must be established and followed. Processes related to uniform evaluation procedures, recipient and donor data collection, quality assurance procedures, outcome analysis, and accountability should also be established. The technician must follow SOPs regarding consent of the family for corneal donation; obtaining medical history in a uniform manner; and ensuring that there are no specific contraindications for donation, such as positive human immunodeficiency virus status, hepatitis status, or an injectable drug abuser profile. The technician should also rule out active infection of the eye. Other SOPs cover the acquisition of tissue and serologic testing. The medical director oversees all these tasks performed by the technician and ensures an equitable system for the transplant waiting list, with priority given to younger patients and individuals with bilateral blindness.

Factors for success

Corneal transplantation is one of the most successfully performed tissue transplant procedures. The unique properties of corneal transplants have been previously described in the medical literature.19 Specifically, research suggests that corneal transplantation success rates have been associated with the immune privilege status of the avascular cornea. Disparity between recipient and donor at the major histocompatibility complex (HLA) is the predominant reason for allograft rejection and the need for immunosuppressive therapy in other transplanted tissues. For corneal transplantation, however, a large, multicenter study showed that neither HLA-A, -B, nor HLA-DR antigen matching reduced corneal graft failure and ABO blood group matching was also insufficient to reduce the risk of graft failure.20

Recipients of corneal transplant typically require shorter hospital stays (in some cases, just two hours), incur lower hospital charges, and often need only topical immunosuppressive therapy.21 In addition, compared with other transplants in which donor age may play a role, multi-center trials have shown that donor age was unimportant in corneal transplant patients younger than age 75, as long as the endothelial cell count was satisfactory.22

Estimated average cost per patient of corneal transplantation in the U.S. is approximately $16,500.23 In other countries, the cost of corneal transplant ranges from $1,300 to $14,807. Table 1 compares costs of corneal transplant in different countries.23-37

Table 1. Costs of corneal transplant in developing and developed countries

Country Cost*
U.S. $16,500
Guyana Subsidized by our sponsor
Netherlands $7,942–$14,807
Canada $3,171
Singapore $3,710
South Africa $1,300
India $2,100–$2,300
Spain $5,650
Turkey $8,640

*Costs are estimates based on conversions from native currencies to U.S. dollars, and may have changed since the data was initially published.

Availability of corneas in the U.S.

The number of cornea donations in the U.S. is increasing. A 2013 report from 76 domestic and 10 international eye banks cited 72,736 total corneal grafts—a 5.9 percent increase from the previous year. According to the EBAA, 48,229 corneal transplants were performed during 2013 in the U.S., and 29,646 corneas were obtained from donor registries in 2013.32 The success of eye banks in the U.S. is largely attributed to public awareness regarding organ donation.

Due to the EBAA’s efficient framework described previously and to high rates of eye donation, the U.S. has sufficient quantities to both meet domestic demands and provide tissue to international recipients.33 A similar program in the developing world is the National Eye Bank of Sri Lanka, which has emerged as an exemplar of corneal donation and international export of corneas in Asia and serves as a role model for developing countries.34

The EBAA authorizes each eye bank to be responsible for distribution of tissue using a list of professionals and institutions approved to receive ocular tissue. If complications occur, such as rejection of the cornea, the transplant surgeon must notify all eye banks involved in the recovery, processing, storage, final distribution, tissue evaluation, and donor eligibility determination. It is expected that the transplant surgeon will notify the eye bank of surgical complications and one-year follow-up even if the corneal transplant is done in another country. However, disposal of corneas in excess of demand depends on the individual eye bank and on the relationship established between them and the U.S. or foreign corneal transplant surgeons.

PPP model at work

Humanitarian missions are essential to meet the need for sight restoration in developing countries, and several organizations in the U.S. support the growth of eye banks around the developing world. There are variations on our model of PPP that include training of local surgeons and funding from private sources in the U.S. or internationally. In 2013, for example, the Lions Eye Bank of Delaware Valley, Philadelphia, PA, provided corneas to transplant surgeons for a mission in Kenya.35 The San Diego Eye Bank, CA, is involved in the International Cornea Project, which is responsible for missions to provide corneas for transplantation around the world.36 Another example is the Cornea Research Foundation, which sponsored a surgeon to teach advanced surgical techniques to Nepali surgeons.37

Dr. Waller (right) and a local physician examine a patient before surgery.

Dr. Waller (right) and a local physician examine a patient before surgery.

At the beginning of 2014, we realized that there was an acute need in Guyana for subspecialty surgical services, in addition to kidney transplantation. We took an incremental approach by reviewing the need for corneal transplantation. This analysis was subjective, as Guyana has no centralized registry for eye diseases. On the first visit, Dr. Waller discussed eye banking and transplantation with Guyanese ophthalmologists and screened 20 patients, eight of whom were suitable candidates for corneal transplants; the transplants were subsequently performed for six patients. Dr. Waller joined the team on its 19th visit and performed the corneal transplants during the 20th visit. Other members of the team continued their work with kidney transplantation and related procedures during these visits.

The six successful corneal transplants were performed within a week by the Guyanese surgeon under the supervision of Dr. Waller. Donor age ranged from 26 to 75 years old (mean 63 years). Endothelial cell count ranged between 2,101 and 3,195 cells/mm2 (mean 2,509 cells/mm2). Recipient age ranged from 20 to 72 years (mean 39 years). Most (83.3 percent) of the recipient population were male. The diagnosis leading to corneal blindness included keratoconus with apical scar (three patients), pseudophakic bullous keratopathy (one patient), leucomatous corneal opacity (one patient), and trauma (one patient). The operation performed on all patients was penetrating keratoplasty. All patients had improvement in their vision postoperatively (see Table 2). No complications were noted, except in the case of the patient with traumatic eye injury, who experienced mild epithelial haze at six months’ follow-up.

Table 2. Recipient information

Recipient Age (years) and sex* Diagnosis Procedure Previous visual acuity Postoperative corrected visual acuity Complications

1

22 F

Keratoconus with apical scar Penetrating keratoplasty

6/24

6/9 (pinhole)

N/A

2

20 M

Keratoconus with apical scar Penetrating keratoplasty

1/60

6/9

N/A

3

48 M

Pseudophakic bullous keratopathy Penetrating keratoplasty

HM

6/9

N/A

4

36 M

Leucomatous corneal opacity Penetrating keratoplasty

HM

6/6

N/A

5

72 M

Post bee sting corneal decompensation Penetrating keratoplasty with cataract extraction with intraocular lens implant

HM

6/36

Mild sub-epithelialhaze with high astigmatism

6

36 M

Keratoconus with apical scar Penetrating keratoplasty

4/60

6/9

N/A

*F-Female, M-Male; Penetrating keratoplasty with cataract extraction with intraocular lens implant; Hand motions close to face.

Dr. Stephen Guy (left) and Dr. Jindal discuss ultrasound findings on a kidney transplant patient. The local Guyanese radiologist (right) is Dr. Panchal.

Dr. Stephen Guy (left) and Dr. Jindal discuss ultrasound findings on a kidney transplant patient. The local Guyanese radiologist (right) is Dr. Panchal.

Our work was made possible because of an intricate partnership between the private and public sectors. In a developing country like Guyana, few patients could afford the cost of corneal transplantation. The Guyanese government plays a significant role in facilitating physician licenses and liability coverage, and importing generic medications, free of charge to the patients, while local medical staff identifies patients and provides pre- and postoperative care under the supervision of Dr. Waller in case of corneal transplants and Dr. Jindal in case of kidney transplants. Our team continues to advise Guyanese physicians via e-mails/Skype and telephone calls on postoperative care.

Ensuring sustainability

Conventionally, limited tissue availability and a lack of trained personnel have made corneal transplants in developing countries unaffordable and inaccessible. A sustainable corneal transplant capacity in a developing country requires skilled local surgeons, and our team engaged in teaching and supervising local surgeons. We also are working with the government of Guyana to establish an eye bank based on U.S. standards.

In addition, a waiting list is being generated so that corneas can be optimally allocated for transplantation. Two corneas that our team brought to Guyana from the U.S. went unused as one patient who was screened in the initial visit declined surgery, and the other procedure was canceled because of the patient’s uncontrolled diabetes. Care will be taken to avoid these situations in the future by creating a larger waiting list of suitable patients and by ensuring that local eye surgeons examine transplant candidates at regular intervals to verify suitability for transplantation. At press time, the U.S. team’s next visit was scheduled to take place in April 2015.

Patients, the government of Guyana, and the media appreciate that U.S. surgeons have undertaken a complex surgical procedure using corneas donated by U.S. patients as illustrated by positive reports in the Guyanese press.24,25 Ultimately, we strive to ensure that corneal transplants in Guyana involve appropriate and equitable patient selection, well-trained and informed surgeons, and meticulous follow-up care.

Acknowledgements

The authors would like to acknowledge the contributions made by the following individuals to both this article and the corneal transplant program: George Subraj, philanthropist and president, Zara Realty, Queens, NY, who funded the program; the Government of Guyana for providing the use of facilities and medications; the staff of Balwant Singh’s Hospital, Georgetown, Guyana, where the transplants were performed; and Neeraj Jain, MD, eye surgeon at Balwant Singh’s Hospital, for compiling the waiting list, follow-up data, and performing the corneal transplants under the supervision of Dr. Waller.

Disclaimer

The views expressed in this article are those of the authors and do not reflect the official policy of the U.S. Department of the Army, the U.S. Department of Defense, or the U.S. government. No financial conflict of interest exists.


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  22. Writing Committee for the Cornea Donor Study Research Group, Mannis MJ, Holland EJ. The effect of donor age on penetrating keratoplasty for endothelial disease: Graft survival after 10 years in the Corneal Donor Study. Ophthalmology. 2013;120(12):2419-2427.
  23. The Lewin Group, Inc. The cost-benefit analysis of corneal transplant. Available at: www.restoresight.org/wp-content/uploads/2014/03/Lewin-Study-Sept-2013.pdf. Accessed January 4, 2015.
  24. Campbell K. Six successful cornea transplants completed at Balwant Singh Hospital 2014. iNews Guyana. Available at: www.inewsguyana.com/six-successful-cornea-transplants-completed-at-balwant-singh-hospital/. Accessed February 8, 2015.
  25. Balwant Singh Hospital successfully performs six corneal transplant operations. Guyana Times. August 2, 2014. Available at: www.guyanatimesgy.com/2014/08/02/balwant-singh-hospital-successfully-performs-six-cornea-transplant-operations/. Accessed March 19, 2015.
  26. van den Biggelaar FJ, Cheng YY, Nuijts RM, et al. Economic evaluation of endothelial keratoplasty techniques and penetrating keratoplasty in the Netherlands. Am J Ophthalmol. 2012;154(2):272-281.
  27. Roussy JP, Aubin MJ, Brunette I, Lachaine J. Cost of corneal transplantation for the Quebec health care system. Can J Ophthalmol. 2009;44(1):36-41.
  28. Tan TE, Peh GS, George BL. A cost-minimization analysis of tissue-engineered constructs for corneal endothelial transplantation. PloS One. 2014;9(6):1-9.
  29. Meyer D. The new challenge of corneal transplantation in South Africa. S Afr Med J. 2007;97(7):512.
  30. We Care India. Low Cost Lasik Eye Surgery. Available at: www.wecareindia.com/eye-surgery/price-guide.html. Accessed on January 23rd, 2015.
  31. Treatment Abroad. Compare the cost of cornea transplant abroad. Available at: www.treatmentabroad.com/costs/eye-surgery/cornea-transplant. Accessed March 19, 2015.
  32. Eye Bank Association of America. 2013 Eye Banking Statistical Report. Available at: www.restoresight.org/wp-content/uploads/2014/04/2013_Statistical_Report-FINAL.pdf. Accessed January 5, 2015.
  33. Eye Bank Association of America. Available at: www.restoresight.org/. Accessed January 12, 2015.
  34. National Eye Bank of Sri Lanka. Available at: www.nationaleyebank.lk/AboutUs.php. Accessed February 10, 2015.
  35. Lions Eye Bank of Delaware Valley. Helping those who need it most. forSight. Available at: www.lebdv.org/images/stories/newsletters_annual-reports/2014 lebdv forsight.pdf. Accessed March 9, 2015.
  36. San Diego Eye Bank. Available at: www.sdeb.org/. Accessed February 10, 2015.
  37. The Visionary. Available at: http://www.cornea.org/About-Us/Visionary-Archives.aspx. Accessed February 6, 2015.

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American College of Surgeons Foundation: An Enduring Legacy, Annual Report 2014 http://bulletin.facs.org/2015/05/acs-foundation-annual-report-2014/ http://bulletin.facs.org/2015/05/acs-foundation-annual-report-2014/#comments Fri, 01 May 2015 05:55:00 +0000 http://bulletin.facs.org/?p=13005 The ACS Foundation’s Annual Report 2014 outlines notable Foundation activities for the past year, including the support of scholarship funds, fellowships, and other philanthropic initiatives.

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ACS Annual Report The ACS Foundation’s Annual Report 2014 outlines notable Foundation activities for the past year, including the support of scholarship funds, fellowships, and other philanthropic activities.

2014 Annual Report

 

 

 

 

 

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Statement in support of motorcycle helmet laws http://bulletin.facs.org/2015/05/statement-in-support-of-motorcycle-helmet-laws/ http://bulletin.facs.org/2015/05/statement-in-support-of-motorcycle-helmet-laws/#comments Fri, 01 May 2015 05:54:28 +0000 http://bulletin.facs.org/?p=13007 The following statement in support of motorcycle helmet laws was originally developed by the Subcommittee on Injury Prevention and Control of the ACS Committee on Trauma. The ACS Board of Regents approved this updated statement at its February 6–7 meeting.

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The following statement was originally developed by the Subcommittee on Injury Prevention and Control of the American College of Surgeons (ACS) Committee on Trauma and published in the February 2001 issue of the Bulletin. The ACS Board of Regents approved this updated statement at its February 2015 meeting.

Total care of the trauma patient includes endorsement of measures designed to prevent or reduce injuries. Regarding the use of motorcycle helmets, the ACS recognizes the following:

  • Helmets reduce the risk of death and head injury in motorcycle riders who crash.
  • It is estimated that between 1982 and 2001, more than 12,000 motorcyclists lost their lives as a result of not using a helmet.
  • Unhelmeted motorcyclists are 40 percent more likely than a helmeted rider to sustain a fatal head injury and 15 percent more likely to suffer a non-fatal injury.
  • Helmeted motorcycle riders have up to an 85 percent reduced incidence of serious, severe, and critical brain injuries compared with unhelmeted riders.
  • Motorcyclists with a brain injury incur average inpatient health care costs that are more than twice the costs incurred by hospitalized motorcyclists without a brain injury.
  • A large portion of the economic burden of motorcycle crashes is borne by the public.
  • When universal helmet use laws are enacted, helmet use increases to nearly 100 percent, and fatalities and serious injuries decrease.
  • When universal helmet use laws are repealed, helmet use decreases and fatality and serious brain injury rates increase.

Therefore, the ACS supports efforts to enact and sustain universal helmet laws for motorcycle riders.


Bibliography

Bellal J, Anderson KT, Rhee P, et al. Universal helmet laws reduce traumatic brain injuries in young motorcyclists. Available at: www.facs.org/media/press-releases/2014/anderson1028. Accessed March 16, 2015.

Coben JH, Steiner CA, Miller TR. Characteristics of motorcycle-related hospitalizations: Comparing states with different helmet laws. Accident Analysis Prev. 2007;39(1):190-196.

Croce MA, Zarzaur BL, Magnotti LJ, Fabian TC. Impact of motorcycle helmets and state laws on society’s burden—a national study. Ann Surg. 2009;250(3):390-439.

Cummings P, Rivara FP, Olson CM, Smith KM. Changes in traffic crash mortality rates attributed to use of alcohol, or lack of a seat belt, air bag, motorcycle helmet or bicycle helmet, United States, 1982–2001. Inj Prev. 2006;12(3):148-154.

Hooten KG, Murad GJA. Helmeted vs nonhelmeted: A retrospective review of outcomes from 2-wheeled vehicle accidents at a Level 1 trauma center. Clin Neurosurg. 2012;59:126-130.

Hundley JC, Kilgo PD, Miller PR, et al. Non-helmeted motorcyclists: A burden to society? A study using the National Trauma Data Bank. J Trauma. 2004;57(5):944-949.

Kraus JF, Peek C, McArthur DL, Williams A. The effect of the 1992 California motorcycle helmet usage law on motorcycle crash fatalities and injuries. JAMA. 1992;272:1506-1511.

Liu BC, Ivers R, Norton R, et al. Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev. 2004;(2):CD004333.

Max W, Stark B, Root S. Putting a lid on injury costs: The economic impact of the California motorcycle helmet law. J Trauma. 1998;45(3):550-556.

National Highway Traffic Safety Administration. Traffic safety facts. Motorcycle Helmet Use Laws. DOT HS 810 887W. January 2008. Available at: www.transportation.nebraska.gov/nohs/pdf/TSFMCHelmetUseLaws2008.pdf. Accessed March 16, 2015.

United States General Accounting Office: Highway Safety: Motorcycle Hemet Laws Save Lives and Reduce Costs to Society. (GAO/RCED-91-170). Washington DC: U.S. General Accounting Office, July 1991.

Watson GA, Zador PL, Wilks A. The repeal of helmet use laws and increased motorcycle mortality in the United States (1975–1978). Am J Pub Health. 1980;70(6):579-585.

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Statement on physician tiering and narrow network programs http://bulletin.facs.org/2015/05/statement-on-physician-tiering-and-narrow-network-programs/ http://bulletin.facs.org/2015/05/statement-on-physician-tiering-and-narrow-network-programs/#comments Fri, 01 May 2015 05:53:31 +0000 http://bulletin.facs.org/?p=13011 The following statement was developed by the American College of Surgeons (ACS) Health Policy and Advocacy Group and was approved by the ACS Board of Regents at its February 2015 meeting. As health care plans create incentives to improve quality and reduce costs, many entities have started using physician-tiering protocols directing patients to choose certain […]

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The following statement was developed by the American College of Surgeons (ACS) Health Policy and Advocacy Group and was approved by the ACS Board of Regents at its February 2015 meeting.

As health care plans create incentives to improve quality and reduce costs, many entities have started using physician-tiering protocols directing patients to choose certain physicians; or they are offering a narrow network, reducing the number of available providers. Both of these protocols rank physicians based on cost, and some networks rank providers based on quality, as well. These protocols are often improperly implemented, rely on faulty data, use inappropriate cost measures, lack transparency, and lead to the misclassification of physicians. The College regards the provision of high-quality surgical care as a top priority and strongly urges that federal or state government agencies, hospitals, health care organizations, insurance companies, or other interested parties develop policies to ensure that every consideration be given to patients so they receive the highest quality surgical care.

Given the current state of performance measurement in health care, the ACS believes that tiering or narrowing accessibility of out-of-network physicians should be based on quality of care rather than cost of care. Although the ACS agrees with efforts that appropriately lead to the efficient delivery of care, we believe that such protocols should be based solely on quality until reliable and valid methods evaluating both cost and quality are available, ensuring the smallest potential risk of misguiding patients who are seeking surgical care. Cost alone should never be considered an adequate metric, and patients should understand that access to reasonable care may be limited when such payor-based programs are imposed on plan benefits without regard to quality.

The ACS supports the following physician tiering and narrow network programs:

  • Programs that use transparent methods and are rooted in logic that patients, physicians, and other stakeholders in the delivery system can comprehend.
  • Programs that use quality measures that meet nationally accepted standards for quality based on importance, scientific acceptability, feasibility, and usefulness. Composite measures that combine quality and cost should be held to the same high standards and should include regular audits for reliability and validity.
  • Programs that have metrics that incorporate care from all appropriate providers and are in accordance with nationally recognized standards. Health care delivery is an outcome of the actions of many individuals and the systems that support them.
  • Programs that incorporate accepted risk adjustments for outcomes and socioeconomic status to ensure ongoing access for patients who are at higher risk for complications and poor outcomes.
  • Programs that involve physicians and physician organizations in the development and implementation of any protocol.
  • Programs that never tier physicians or remove physicians from health plan networks based on cost alone. Payors should rely on nationally validated and reliable quality metrics, and while cost data should be transparently available to patients to allow them to apply cost information independently in the decision-making process, these data should not be used to make network decisions.
  • Programs that set appropriate benchmarks that incentivize all physicians to achieve optimal clinical outcomes and high-value care.
  • Programs that impose minimal burdens on physicians so as to avoid impeding the provision of care or patient access to care.
  • Programs that provide an opportunity for patients, physicians, or other stakeholders in the delivery system to appeal any classification of the physician in the program.

The ACS is not aware of any physician tiering or narrow network programs that meet these criteria. This gap is likely due, in part, to the lack of transparency associated with these program. The ACS recommends that payors discontinue such programs and direct their efforts toward quality measures currently available to encourage providers to participate in learning health systems and quality improvement efforts. However, if measures of both quality and cost are used for these programs, the metrics used must be explicitly stated. This transparency is necessary so that patients can understand that access to care may be limited when such programs impose restrictions without regard to quality. Entities should partner with physician stakeholders if they are interested in developing reliable resource-use measures that do not run the risk of denying patients access to quality care.

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One surgeon’s principles http://bulletin.facs.org/2015/05/one-surgeons-principles/ http://bulletin.facs.org/2015/05/one-surgeons-principles/#comments Fri, 01 May 2015 05:52:10 +0000 http://bulletin.facs.org/?p=13015 The author of this month’s column shares his 10 principles for the provision of care—words of wisdom culled from nearly 50 years as a surgeon.

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I am in my 80s, and I know myself most fortunate to be able to make that statement. I have been a surgeon for nearly 50 years. I am grateful for those years of doing what I believe I was meant to do while enjoying almost every moment of that time. I am an academic who holds a dual appointment in surgery and biomedical engineering. In that role, I have attempted to be a mentor to residents in terms of surgical care, technique, and the attributes of practice that govern our discipline.

Over the years, based on my experience, I have formulated certain principles regarding the provision of care that have guided my career. I offer these 10 principles in the hope that they may be of interest to others.

It’s always your fault

Except for liability litigation, this precept is a good way to approach the acceptance of responsibility for the well-being and the life that a patient entrusts to you. Anticipate exigencies and attempt to prevent untoward events. Acknowledge bad decisions, even if they appeared to be the most rational choices when they were made. When assessing a bad outcome, recognize that there are no acts of God. I tell residents that if a patient falls out of bed, it’s their fault.

Postoperative complications can be solved intraoperatively

Carefully plan your contemplated procedure beforehand. Do every dissection, every anastomosis, and every operative step in your imagination before you enter the operating room. Intraoperative care and thought, careful technique, refusal to compromise for convenience, redoing a repair if in doubt, and constant reflection often will prevent the agonies of complications for your patient. Further, no matter how often I have done a particular procedure, before the patient is closed or the instruments removed, I replay the entire operation in my mind. If I am not satisfied with my mental video, I go back and try to remedy my concerns.

Gentleness, not speed, is the cardinal surgical virtue

Paraphrasing a surgical maxim from the 15th century, Harvey Cushing, MD, FACS, allegedly told aspiring surgeons: “The surgeon should have the eye of the eagle, the heart of the lion, and the hand of the woman.” Unfortunately, some surgeons have gotten these precepts confused and exhibit the “hand” of the lion or the eagle. Fortunately, we now have many outstanding women surgeons who quite naturally exhibit the hand of the woman. In Europe, speed is sometimes valued for its own sake. Continental surgeons often boast about how quickly they can do a procedure, as if they lived in the 19th century. However, in the age of advanced anesthesia and respiratory control, speed is a poor second to gentleness. Tissues are delicate; handle them carefully. Bleeding can almost always be avoided. Adhesions can be teased apart. The proper wrist posture when sewing with a curved needle will avoid suture cut marks. The finer the anastomotic suture material, the less likely a leak or stenosis will occur.

A learning curve can take time but should not take lives

It revolts me to hear surgeons boast of lowering their mortality rates during their learning curve. When a surgeon emerges from training, the surgeon should expect no mortality or significant morbidity because of a lack of skill. A learning curve should never be measured in patient mortality, but should rather be determined by time involved in performing a procedure and improvement in technical skills.

Venerate life

The employment of care conferences in intensive care units, wherein every person who has had contact with the patient— as well as an exogenous ethicist, in some cases—recommend life or death to a patient’s family has become ubiquitous. Reinhold Niebuhr, a 20th century American theologian, abhorred decision making by a committee and put his trust in the individual. For a surgical patient, that individual should be the surgeon. If the patient does not have untreatable cancer, dementia, or a terminal diagnosis, the surgeon should, in my opinion, be the advocate for life, even if limited, and not for death. Further, with respect to ageism in making surgical decisions, I have known a surgeon who in case discussions commonly expressed the opinion that attempting an operation or providing all-out care should be tempered and possibly not offered when the patient was more than 65 years old. I have always believed (even before I reached that age) that people older than age 65 deserve to live and should have any surgical procedure deemed necessary.

Be proud of your craft

I attended medical school on the East Coast, where, as a rule in those long-gone days, surgeons were considered dummies, the cast-offs of medical training. Many years later, I was invited to consider a job offer as chief of surgery at a prestigious northeastern university. I was told that the internists would work-up my patients and decide for or against a procedure; that the anesthesiologists would take care of them during and immediately after an operation; and that the internists, with the help of their specialists in cardiology, would then again take over their care. I asked, “What is left for me to do?” My escort was surprised by my question and responded, “You operate, of course.” In other words, the surgeon was still viewed by some as a technician. I have always denied that conception of our role. I believe the surgeon is an internist who can use his/her hands to follow through on what the mind dictates. In other words, competence in manual dexterity does not preclude cognitive ability.

Think creatively

Laboratory or clinical research leads to invention, and invention is the product of imagination. The imaginative process can be stunted by over-reading or over-analyzing at the beginning of the process. An idea should be dissected, contemplated, and relished by its originator before it is subjected to critical examination. After indulging the initial thought, however, it is time to explore the literature and re-examine the concept for originality and feasibility. If others have not previously and definitively conducted the experiment, or there are no strong data indicating that the concept cannot be made a reality, then it is time to plan the investigation and, if the search for funding is successful, to initiate the study. Thus, my research advice is this: think first, then read, then think again, but perhaps don’t read voluminously at first, for that may inhibit a good thought.

Be of service to the community

Sooner or later, we should emerge from the shelter of our working and personal time and engage in community activities, such as joining service organizations or initiating a novel contribution to society. In my case, I chose, together with Arthur J. Roberts, MD, FACS, a former cardiovascular surgeon and professional football quarterback, and with the endorsement of the National Football League (NFL) Players Association, to start the Living Heart Foundation-Heart, Obesity, Prevention & Education (LHF-HOPE) program. This activity screens former NFL players throughout the country for obesity, diabetes, heart disease, hypertension, and other ailments, and refers them for further diagnostics and therapy to a regional center of excellence. In phase two of the LHF-HOPE program, lectures are scheduled featuring former players who have reclaimed their good health. They speak on the hazards of obesity and other health care problems to professional organizations and industry groups. They also participate in public forums and presentations to the media. Since the public doesn’t typically pay a great deal of attention to suggestions by members of the medical profession and by most lay advisory groups, it is our hope that they might listen to some of the country’s most admired athletes—football players.

Know where we are in our professional time continuum

Surgery has moved from incisional (such as draining abscesses) to centuries of excisional procedures (primarily for cancer), to reparative cardiac, transplantation, and implantation operations. We maintain this heritage, but we must also move forward into the next phase of our discipline, namely, metabolic surgery. We are focusing on technology—laparoscopic, robotic, single orifice, natural orifice transluminal endoscopic surgery. But, no matter how beguiling technologic change is, we need to embrace the paradigm shift to metabolic surgery, which the late Richard L. Varco, MD, FACS, and I defined in 1978 as “the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain.”*

There are myriad examples of metabolic surgery, starting with surgery for peptic ulcer disease, where surgeons operated on normal stomachs and vagal nerves without touching yet healed the pathologic lesion—the duodenal ulcer. Presently, metabolic surgery is best represented by bariatric surgery, where surgeons operate on the gastrointestinal tract to achieve a neurohormonal shift in metabolism in order to engender weight loss and ameliorate obesity comorbidities. The ultimate goal of metabolic surgery research is knowledge of the mechanisms and etiology of the diseases we treat (for example, diabetes).

Joy is in the process

Successful outcomes are satisfying and awards are gratifying, but the joy of surgery is in the process—the daily events of caring for patients, thinking about a new problem and thinking anew about an old one, the unpredictability and ever-changing novelty of events, and the physical pleasure of working with your hands.

The word “surgery” is derived from the Greek words “cheiros,” a hand, and “ergon,” work. In essence, we are defined as hand laborers. Thus, as surgeons we live a continuous adventure, are physically active, and literally able to shape events not only with our minds, but with our hands. It is only fitting that my 10 principles conclude with the fact that a surgeon will spend the majority of his or her life in the practice of this chosen vocation. Therefore, take joy in the process.

Note

This column is based on the graduation address that Dr. Buchwald delivered when he was accorded Honorary Fellowship in the Royal College of Surgeons of England in March 2014.


*Buchwald H, Varco RL (eds). Metabolic Surgery. New York, NY, USA: Grune and Stratton; 1978.

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Limited resection as a cure for early lung cancer: Time to challenge the gold standard? http://bulletin.facs.org/2015/05/limited-resection-as-a-cure-for-early-lung-cancer-time-to-challenge-the-gold-standard/ http://bulletin.facs.org/2015/05/limited-resection-as-a-cure-for-early-lung-cancer-time-to-challenge-the-gold-standard/#comments Fri, 01 May 2015 05:51:32 +0000 http://bulletin.facs.org/?p=13020 A clinical trial is exploring whether limited resection should replace lobectomy as the gold standard for treatment of early-stage lung cancer.

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Lung cancer remains the leading cause of cancer-related death in the U.S. With increased use of diagnostic and screening computed tomography (CT) scans, many lung cancers are discovered when they are small (≤ 2 cm). Do these small cancers require a standard lobectomy, or can a more limited resection, such as wedge resection or segmentectomy along with identical lymph node dissection, provide a similar oncologic outcome?

An active North American Phase III trial, Cancer and Leukemia Group B (CALGB) 140503, is expected to help determine whether small cancers require a standard lobectomy. The clinical trial is designed to reveal whether a limited resection (wedge resection or segmentectomy) provides equivalent survival to a lobectomy for treatment of early-stage non-small cell lung cancer (NSCLC). The current “gold standard” of lobectomy for NSCLC was established by the 1995 Lung Cancer Study Group (LCSG) trial that randomized patients with peripheral stage 1 (up to 3 cm) NSCLC to lobectomy versus limited resection in 267 patients. Survival results were not statistically different between the two groups, but lobectomy was favored because of fewer loco-regional recurrences.1

Ongoing advances

It has been 20 years since the results of the LCSG trial were published in the Annals of Thoracic Surgery.1 Over the course of these two decades, significant advances have occurred in screening, staging, and treatment of early-stage lung cancer. CT scanning, which can detect much smaller nodules, is now universally used for both diagnosis and screening. New generation CT and positron emission tomography scans provide more accurate noninvasive assessment and staging, including the ability to distinguish between solid, part-solid, and slow-growing non-solid lesions, which have a more indolent course.

Japanese oncologists were the first to identify a group of patients who could achieve high survival rates with limited resection.2-4 Many surgeons now have experience with segmentectomy, both open and video-assisted, making sublobar resection feasible and applicable for more of these patients. In addition, single institution studies have shown that limited lung resection provides similar local control and survival to lobectomy in well-selected patients.5-7 The timing is right to challenge the gold standard of lobectomy for early-stage NSCLC in a multicenter trial.

CALGB 140503

CALGB 140503

CALGB 140503

CALGB 140503 is a Phase III randomized trial of lobectomy versus sublobar resection for small (≤ 2 cm) peripheral NSCLC. Since 2007, 533 patients have been randomized, making this the largest multicenter trial evaluating this question. Target accrual is 692, more than twice the LCSG accrual.

Eligible patients include those who are older than 18 years of age with a peripheral lung nodule measuring ≤ 2 cm on a CT scan and suspected or proven lung cancer. The nodule must be peripherally located (defined as in the outer one-third of the lung) and the patient physiologically suited for either lobectomy or limited resection. Patients must not have had a previous malignancy within three years (with the exception of non-melanoma skin cancer, superficial bladder cancer, or cervical carcinoma in situ). Excluded from this trial are patients who have previously undergone chemotherapy and/or radiotherapy, as well as patients with locally advanced or metastatic disease. Patients are registered before surgery. During surgery, the cancer diagnosis is confirmed, if not previously determined by preoperative biopsy, and the required regional nodes are determined to be negative by frozen section (levels 4, 7, and 10 on the right; levels 5 or 6, 7, and 10 on the left) (see figure, this page). The patient is then intraoperatively randomized to either limited resection or lobectomy. Patients are followed for five years to determine disease-free and overall survival rate.

The results of CALGB 140503 are vital for evaluating the surgical management of patients with early stage lung cancer (T1aN0), a population that is under-represented in clinical trials. The implementation of CT screening for lung cancer, now approved by the Centers for Medicare & Medicaid Services, will result in the diagnosis of even more small peripheral lung cancers for which surgical treatment will be indicated.8 Many of these patients have poor lung function related to prior smoking behavior. Preservation of lung function by limited resection, if equal to lobectomy in cancer control, will result in a better quality of life for these individuals and maximize options for treatment of future second primaries.

Surgeons are urged to contribute to these research efforts by recommending this trial for their eligible patients to help determine the optimal extent of surgical resection for oncologic control of early-stage lung cancer, and decide whether it’s time to change the gold standard of lobectomy for early-stage NSCLC.


References

  1. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995;60(3):615-622.
  2. Koike T, Yamato Y, Yoshiya K, Shimoyama T, Suzuki R. Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer. J Thorac Cardiovasc Surg. 2003;125(4):924-928.
  3. Okada M, Nishio W, Sakamoto T, et al. Effect of tumor size on prognosis in patients with non-small cell lung cancer: The role of segmentectomy as a type of lesser resection. J Thorac Cardiovasc Surg. 2005;129(1):87-93.
  4. Okada M, Yoshikawa K, Hatta T, Tsubota N. Is segmentectomy with lymph node assessment an alternative to lobectomy for non-small cell lung cancer of 2 cm or smaller? Ann Thorac Surg. 2001;71(3):950-960.
  5. Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer. J Thorac Cardiovasc Surg. 1997;113(4):691-698.
  6. Read RC, Yoder G, Schaeffer RC. Survival after conservative resection for T1 N0 M0 non-small cell lung cancer. Ann Thorac Surg. 1990;49(3):391-398.
  7. Keenan RJ, Landreneau RJ, Maley RH Jr, et al. Segmental resection spares pulmonary function in patients with stage I lung cancer. Ann Thorac Surg. 2004;78(1):228-233.
  8. Centers for Medicare & Medicaid Services. Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). February 5, 2015. Available at: www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Accessed March 1, 2015.

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ACS Archives houses practice records of Franklin H. Martin http://bulletin.facs.org/2015/05/acs-archives-houses-practice-records-of-franklin-h-martin/ http://bulletin.facs.org/2015/05/acs-archives-houses-practice-records-of-franklin-h-martin/#comments Fri, 01 May 2015 05:50:20 +0000 http://bulletin.facs.org/?p=13025 The ACS Archives house four record books detailing the gynecologic practice of Franklin H. Martin, MD, FACS.

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Dr. Martin’s practice records book: a cover with red rot.

Dr. Martin’s practice records book: A cover with red rot.

Dr. Martin’s practice records book: a laparotomy record.

Dr. Martin’s practice records book: A laparotomy record.

Detail of Dr. Martin’s laparotomy record.

Detail of Dr. Martin’s laparotomy record.

Among the prized holdings in the American College of Surgeons (ACS) Archives are the papers of ACS founder Franklin H. Martin, MD, FACS, and his wife, Isabelle H. Martin. Within that collection are the four record books of Dr. Martin’s gynecology practice. One labeled “Laparotomy” was used from 1891 to 1900, and the other three record books highlight Dr. Martin’s practice from 1896 to 1917.

Renowned gynecologist

Dr. Martin received his medical degree in 1880 from the Chicago Medical College (now Northwestern University’s Feinberg School of Medicine, Chicago, IL), and from 1886 to 1888, he was a professor of gynecology at a postgraduate medical school called the Chicago Policlinic. Dr. Martin read his first authored paper, “Treatment of fibroid tumors of the uterus by electrolysis, with a description of Apostoli’s Method,” at a meeting of the American Medical Association in 1886. The following year, he began his long tenure as a gynecologist at the Women’s Hospital of Chicago. During that time, he authored A Treatise on Gynecology.

Patients traveled long distances, even by today’s standards, to see Dr. Martin. In addition to Chicago, there are many patient addresses from Indiana, Michigan, Missouri, and Iowa recorded in the practice records. Interestingly, the names of married patients were entered using the husband’s name (for example, Mrs. John Jones, rather than Mrs. Jane Jones).

Records survive improper storage

For many decades, these practice records books were kept next to the boiler room in the basement of the John B. Murphy Memorial Auditorium, Chicago, and were subject to sporadic heating and air conditioning. In 2002, the books were transferred to the Archives located in the College’s headquarters in Chicago, but their leather bindings had already deteriorated with age (“red rot”) and are in need of conservation treatment. The pages, however, are in very good condition. Laid within the pages are hand-drawn illustrations, various notes on loose sheets, and completed test result forms. One sheet of instructions to a patient advises, “All undergarments… should consist exclusively of wool…. No cotton, silk, or linen fabric should be permitted in contact with the skin.”

A full listing of the 96 boxes of Dr. Martin’s papers can be found in the Archives section of the College’s website. We welcome your suggestions for any other artifacts from the ACS Archives that you would like to see featured in this column.

 

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