Jim Kling

SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.

“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.

The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.

The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.

The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.

A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.

The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).

ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days

Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).

There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.

The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.

SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.

“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.

The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.

The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.

The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.

A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.

The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).

ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days

Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).

There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.

The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.

SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.

“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.

The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.

The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.

The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.

A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.

The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).

ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days

Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).

There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.

The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.

The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.

In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.

There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.

“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.

The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.

“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.

That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.

The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.

High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).

In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).

In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).

The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).

Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.

The study received no outside support. Dr. Vuong reported having no financial disclosures..

SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.

The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.

In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.

There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.

“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.

The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.

“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.

That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.

The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.

High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).

In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).

In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).

The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).

Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.

The study received no outside support. Dr. Vuong reported having no financial disclosures..

SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.

The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.

In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.

There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.

“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.

The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.

“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.

That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.

The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.

High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).

In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).

In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).

The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).

Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.

The study received no outside support. Dr. Vuong reported having no financial disclosures..

SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.

There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.

Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.

“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.

The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.

His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.

The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).

In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).

The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.

SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.

There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.

Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.

“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.

The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.

His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.

The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).

In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).

The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.

SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.

There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.

Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.

“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.

The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.

His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.

The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).

In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).

The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.

SCOTTSDALE, ARIZ. – In patients with right upper quadrant pain, the Tokyo Guidelines (TG13) failed to detect acute cholecystitis with adequate sensitivity, according to a single institution retrospective review.

Researchers at the University of Arizona, Tucson, also found that the Tokyo Guidelines’ advice to manage grade II and grade III cholecystitis patients conservatively may be unwarranted, because there were no differences in safety outcomes between grade I and grade II patients who underwent early cholecystectomy.

SCOTTSDALE, ARIZ. – In patients with right upper quadrant pain, the Tokyo Guidelines (TG13) failed to detect acute cholecystitis with adequate sensitivity, according to a single institution retrospective review.

Researchers at the University of Arizona, Tucson, also found that the Tokyo Guidelines’ advice to manage grade II and grade III cholecystitis patients conservatively may be unwarranted, because there were no differences in safety outcomes between grade I and grade II patients who underwent early cholecystectomy.

SCOTTSDALE, ARIZ. – In patients with right upper quadrant pain, the Tokyo Guidelines (TG13) failed to detect acute cholecystitis with adequate sensitivity, according to a single institution retrospective review.

Researchers at the University of Arizona, Tucson, also found that the Tokyo Guidelines’ advice to manage grade II and grade III cholecystitis patients conservatively may be unwarranted, because there were no differences in safety outcomes between grade I and grade II patients who underwent early cholecystectomy.

SCOTTSDALE, ARIZ. – In breast conservation surgery with whole-breast radiation, costs and the number of re-excisions performed at a single institution dropped after the implementation of 2014 consensus guidelines on excision margins.

The guidelines, created by a multidisciplinary margins panel convened by the Society of Surgical Oncology and the American Society for Radiation Oncology recommend “no ink on tumor” as an adequate margin in cases of invasive carcinoma.
 

The guidelines sought to reduce costs and re-excision rates and improve cosmetic outcomes. The results of the study carried out at the University of Louisville suggest that the guidelines may be successful in achieving these goals. The reduced need for re-excision is a key point. “That’s very traumatic for the patient. With this consensus, we were able to decrease that, improve patient satisfaction, and decrease the cost,” lead author Nicolás Ajkay, MD, assistant professor of surgery at the University of Louisville School of Medicine, said in an interview.

Dr. Ajkay presented the results of the study at the annual meeting of the Western Surgical Association.

“Surgeons need to be aware of the guidelines, and if the margin is close, they need to be in multidisciplinary discussions with other breast cancer experts to determine which patients would benefit from going back to the operating room,” he said.

The researchers examined the experiences of 237 patients with stage I or stage II invasive carcinoma who had a partial mastectomy. Of these patients, 126 underwent the procedure before the university incorporated the guidelines in March 2014 (PRE), while 111 were seen after that date (POST). The study excluded those who were diagnosed by excisional biopsy and those who were treated with neoadjuvant chemotherapy.

Per-patient operative costs went down on average after the guidelines were implemented ($4,247 vs. $5,465; difference, $1,218; P less than .001). The estimated savings for the entire POST cohort of 111 patients was approximately $135,000.

Patient satisfaction improved as measured by the breast satisfaction domain of the BREAST-Q survey tool (77/100 vs. 61/100; P = .03).

A multivariate analysis showed that the implementation of the consensus statement predicted lower re-excision rates (odds ratio, 0.17; 95% confidence interval, 0.08-0.38; P less than .001) as well as lower operative cost per patient (cost greater than $5,465 OR, 0.14; 95% CI, 0.07-0.30; P less than .001). Guideline implementation did not, however, predict decreased total resection volume, or probability of conversion to mastectomy.

Perhaps because diagnostic methods have improved over time, there were some significant differences between the two populations. The PRE group had a larger median tumor size (1.5 cm vs. 1.1 cm; P less than .001), and a lower proportion of the PRE group was diagnosed as stage I (62% vs. 77%; P = .005). The PRE group also had significantly larger initial resection volume (69.3 cm³ versus 47.1 cm³; P = .02), higher selective margin volume (50.0 cm³ vs. 11.3 cm³; P less than .001), and a larger final resection volume (81.0 cm³ vs. 51.5 cm³; P = .05). Additional selective margin resection was less frequent in the PRE group (76% vs. 41%; P less than .001).

Those differences may confound the findings, since outcomes might have been expected to improve anyway due to improvements in care.

One member of the audience asked whether the guidelines might boost rates of cancer recurrence. It’s too soon to tell, according to Dr. Ajkay, who said that researchers will need at least 4 or 5 years of clinical experience to make that determination. But he is optimistic. “Even though we’re excising less, I would predict we will not see an increase in recurrence, because adjuvant therapy is getting significantly better, and adjuvant therapy reduces the risk of recurrence just as margin re-excisions do,” he said.

The study received no external funding. Dr. Ajkay reported having no financial disclosures.

SCOTTSDALE, ARIZ. – In breast conservation surgery with whole-breast radiation, costs and the number of re-excisions performed at a single institution dropped after the implementation of 2014 consensus guidelines on excision margins.

The guidelines, created by a multidisciplinary margins panel convened by the Society of Surgical Oncology and the American Society for Radiation Oncology recommend “no ink on tumor” as an adequate margin in cases of invasive carcinoma.
 

The guidelines sought to reduce costs and re-excision rates and improve cosmetic outcomes. The results of the study carried out at the University of Louisville suggest that the guidelines may be successful in achieving these goals. The reduced need for re-excision is a key point. “That’s very traumatic for the patient. With this consensus, we were able to decrease that, improve patient satisfaction, and decrease the cost,” lead author Nicolás Ajkay, MD, assistant professor of surgery at the University of Louisville School of Medicine, said in an interview.

Dr. Ajkay presented the results of the study at the annual meeting of the Western Surgical Association.

“Surgeons need to be aware of the guidelines, and if the margin is close, they need to be in multidisciplinary discussions with other breast cancer experts to determine which patients would benefit from going back to the operating room,” he said.

The researchers examined the experiences of 237 patients with stage I or stage II invasive carcinoma who had a partial mastectomy. Of these patients, 126 underwent the procedure before the university incorporated the guidelines in March 2014 (PRE), while 111 were seen after that date (POST). The study excluded those who were diagnosed by excisional biopsy and those who were treated with neoadjuvant chemotherapy.

Per-patient operative costs went down on average after the guidelines were implemented ($4,247 vs. $5,465; difference, $1,218; P less than .001). The estimated savings for the entire POST cohort of 111 patients was approximately $135,000.

Patient satisfaction improved as measured by the breast satisfaction domain of the BREAST-Q survey tool (77/100 vs. 61/100; P = .03).

A multivariate analysis showed that the implementation of the consensus statement predicted lower re-excision rates (odds ratio, 0.17; 95% confidence interval, 0.08-0.38; P less than .001) as well as lower operative cost per patient (cost greater than $5,465 OR, 0.14; 95% CI, 0.07-0.30; P less than .001). Guideline implementation did not, however, predict decreased total resection volume, or probability of conversion to mastectomy.

Perhaps because diagnostic methods have improved over time, there were some significant differences between the two populations. The PRE group had a larger median tumor size (1.5 cm vs. 1.1 cm; P less than .001), and a lower proportion of the PRE group was diagnosed as stage I (62% vs. 77%; P = .005). The PRE group also had significantly larger initial resection volume (69.3 cm³ versus 47.1 cm³; P = .02), higher selective margin volume (50.0 cm³ vs. 11.3 cm³; P less than .001), and a larger final resection volume (81.0 cm³ vs. 51.5 cm³; P = .05). Additional selective margin resection was less frequent in the PRE group (76% vs. 41%; P less than .001).

Those differences may confound the findings, since outcomes might have been expected to improve anyway due to improvements in care.

One member of the audience asked whether the guidelines might boost rates of cancer recurrence. It’s too soon to tell, according to Dr. Ajkay, who said that researchers will need at least 4 or 5 years of clinical experience to make that determination. But he is optimistic. “Even though we’re excising less, I would predict we will not see an increase in recurrence, because adjuvant therapy is getting significantly better, and adjuvant therapy reduces the risk of recurrence just as margin re-excisions do,” he said.

The study received no external funding. Dr. Ajkay reported having no financial disclosures.

SCOTTSDALE, ARIZ. – In breast conservation surgery with whole-breast radiation, costs and the number of re-excisions performed at a single institution dropped after the implementation of 2014 consensus guidelines on excision margins.

The guidelines, created by a multidisciplinary margins panel convened by the Society of Surgical Oncology and the American Society for Radiation Oncology recommend “no ink on tumor” as an adequate margin in cases of invasive carcinoma.
 

The guidelines sought to reduce costs and re-excision rates and improve cosmetic outcomes. The results of the study carried out at the University of Louisville suggest that the guidelines may be successful in achieving these goals. The reduced need for re-excision is a key point. “That’s very traumatic for the patient. With this consensus, we were able to decrease that, improve patient satisfaction, and decrease the cost,” lead author Nicolás Ajkay, MD, assistant professor of surgery at the University of Louisville School of Medicine, said in an interview.

Dr. Ajkay presented the results of the study at the annual meeting of the Western Surgical Association.

“Surgeons need to be aware of the guidelines, and if the margin is close, they need to be in multidisciplinary discussions with other breast cancer experts to determine which patients would benefit from going back to the operating room,” he said.

The researchers examined the experiences of 237 patients with stage I or stage II invasive carcinoma who had a partial mastectomy. Of these patients, 126 underwent the procedure before the university incorporated the guidelines in March 2014 (PRE), while 111 were seen after that date (POST). The study excluded those who were diagnosed by excisional biopsy and those who were treated with neoadjuvant chemotherapy.

Per-patient operative costs went down on average after the guidelines were implemented ($4,247 vs. $5,465; difference, $1,218; P less than .001). The estimated savings for the entire POST cohort of 111 patients was approximately $135,000.

Patient satisfaction improved as measured by the breast satisfaction domain of the BREAST-Q survey tool (77/100 vs. 61/100; P = .03).

A multivariate analysis showed that the implementation of the consensus statement predicted lower re-excision rates (odds ratio, 0.17; 95% confidence interval, 0.08-0.38; P less than .001) as well as lower operative cost per patient (cost greater than $5,465 OR, 0.14; 95% CI, 0.07-0.30; P less than .001). Guideline implementation did not, however, predict decreased total resection volume, or probability of conversion to mastectomy.

Perhaps because diagnostic methods have improved over time, there were some significant differences between the two populations. The PRE group had a larger median tumor size (1.5 cm vs. 1.1 cm; P less than .001), and a lower proportion of the PRE group was diagnosed as stage I (62% vs. 77%; P = .005). The PRE group also had significantly larger initial resection volume (69.3 cm³ versus 47.1 cm³; P = .02), higher selective margin volume (50.0 cm³ vs. 11.3 cm³; P less than .001), and a larger final resection volume (81.0 cm³ vs. 51.5 cm³; P = .05). Additional selective margin resection was less frequent in the PRE group (76% vs. 41%; P less than .001).

Those differences may confound the findings, since outcomes might have been expected to improve anyway due to improvements in care.

One member of the audience asked whether the guidelines might boost rates of cancer recurrence. It’s too soon to tell, according to Dr. Ajkay, who said that researchers will need at least 4 or 5 years of clinical experience to make that determination. But he is optimistic. “Even though we’re excising less, I would predict we will not see an increase in recurrence, because adjuvant therapy is getting significantly better, and adjuvant therapy reduces the risk of recurrence just as margin re-excisions do,” he said.

The study received no external funding. Dr. Ajkay reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Patients with hyperparathyroidism and single-gland disease can be considered cured if their intraoperative parathyroid hormone (PTH) level drops by 50% or more, or to normal or near-normal levels (15-65 pg/mL), and don’t require immediate follow-up for lab work, according to a retrospective review of patients who underwent parathyroidectomy at Mayo Clinic, Rochester, Minn.

These findings applied only to patients in the study whose preoperative sestamibi scans were concordant with intraoperative findings. Single-gland disease represented about 85% of cases, Melanie L. Lyden, MD, reported at the annual meeting of the Western Surgical Association.

SCOTTSDALE, ARIZ. – Patients with hyperparathyroidism and single-gland disease can be considered cured if their intraoperative parathyroid hormone (PTH) level drops by 50% or more, or to normal or near-normal levels (15-65 pg/mL), and don’t require immediate follow-up for lab work, according to a retrospective review of patients who underwent parathyroidectomy at Mayo Clinic, Rochester, Minn.

These findings applied only to patients in the study whose preoperative sestamibi scans were concordant with intraoperative findings. Single-gland disease represented about 85% of cases, Melanie L. Lyden, MD, reported at the annual meeting of the Western Surgical Association.

SCOTTSDALE, ARIZ. – Patients with hyperparathyroidism and single-gland disease can be considered cured if their intraoperative parathyroid hormone (PTH) level drops by 50% or more, or to normal or near-normal levels (15-65 pg/mL), and don’t require immediate follow-up for lab work, according to a retrospective review of patients who underwent parathyroidectomy at Mayo Clinic, Rochester, Minn.

These findings applied only to patients in the study whose preoperative sestamibi scans were concordant with intraoperative findings. Single-gland disease represented about 85% of cases, Melanie L. Lyden, MD, reported at the annual meeting of the Western Surgical Association.

SAN DIEGO – In patients with Lewy body disease, cerebrospinal fluid biomarkers may predict the extent of Alzheimer’s disease pathology, according to a new postmortem analysis.

In the small prospective study, David Irwin, MD, and his colleagues at the University of Pennsylvania, Philadelphia, found that higher antemortem cerebrospinal fluid (CSF) levels of total tau (t-tau) protein and lower amyloid-beta 1-42 (Abeta 1-42) levels were associated with postmortem evidence of cerebral Alzheimer’s disease and synuclein pathology.

Jim Kling/Frontline Medical News

SAN DIEGO – In patients with Lewy body disease, cerebrospinal fluid biomarkers may predict the extent of Alzheimer’s disease pathology, according to a new postmortem analysis.

In the small prospective study, David Irwin, MD, and his colleagues at the University of Pennsylvania, Philadelphia, found that higher antemortem cerebrospinal fluid (CSF) levels of total tau (t-tau) protein and lower amyloid-beta 1-42 (Abeta 1-42) levels were associated with postmortem evidence of cerebral Alzheimer’s disease and synuclein pathology.

Jim Kling/Frontline Medical News

SAN DIEGO – In patients with Lewy body disease, cerebrospinal fluid biomarkers may predict the extent of Alzheimer’s disease pathology, according to a new postmortem analysis.

In the small prospective study, David Irwin, MD, and his colleagues at the University of Pennsylvania, Philadelphia, found that higher antemortem cerebrospinal fluid (CSF) levels of total tau (t-tau) protein and lower amyloid-beta 1-42 (Abeta 1-42) levels were associated with postmortem evidence of cerebral Alzheimer’s disease and synuclein pathology.

Jim Kling/Frontline Medical News

Ultrasonic surgical aspirator devices should not be used for fragmentation, emulsification, and aspiration of uterine fibroids, according to the Food and Drug Administration.

These devices have the potential to disseminate undetected tumor tissue, and there are no proven preoperative screening methods for detecting uterine sarcoma in uterine fibroids that otherwise appear to be benign, FDA officials wrote in a guidance document issued Oct. 30. The FDA is calling for new product labeling for these devices within 120 days.

Ultrasonic surgical aspirator devices should not be used for fragmentation, emulsification, and aspiration of uterine fibroids, according to the Food and Drug Administration.

These devices have the potential to disseminate undetected tumor tissue, and there are no proven preoperative screening methods for detecting uterine sarcoma in uterine fibroids that otherwise appear to be benign, FDA officials wrote in a guidance document issued Oct. 30. The FDA is calling for new product labeling for these devices within 120 days.

Ultrasonic surgical aspirator devices should not be used for fragmentation, emulsification, and aspiration of uterine fibroids, according to the Food and Drug Administration.

These devices have the potential to disseminate undetected tumor tissue, and there are no proven preoperative screening methods for detecting uterine sarcoma in uterine fibroids that otherwise appear to be benign, FDA officials wrote in a guidance document issued Oct. 30. The FDA is calling for new product labeling for these devices within 120 days.

In patients with acute myocardial infarction and multivessel coronary artery disease with cardiogenic shock, 30-day rates of death and renal-replacement therapy were lower when patients underwent percutaneous coronary intervention (PCI) of the culprit lesion as opposed to multivessel PCI.

The difference appeared to be driven by mortality, as the renal endpoint alone was not significant.

As many as 80% of patients with cardiogenic shock also present with multivessel coronary artery disease, and this is associated with worse mortality. It is unclear whether immediate PCI of clinically important stenoses of major nonculprit coronary arteries is of benefit, and previous randomized trials comparing the procedures did not look at patients with cardiogenic shock, Holger Thiele, MD, reported at the Transcatheter Cardiovascular Therapeutics annual educational meeting.

Bruce Jancin/Frontline Medical News

In patients with acute myocardial infarction and multivessel coronary artery disease with cardiogenic shock, 30-day rates of death and renal-replacement therapy were lower when patients underwent percutaneous coronary intervention (PCI) of the culprit lesion as opposed to multivessel PCI.

The difference appeared to be driven by mortality, as the renal endpoint alone was not significant.

As many as 80% of patients with cardiogenic shock also present with multivessel coronary artery disease, and this is associated with worse mortality. It is unclear whether immediate PCI of clinically important stenoses of major nonculprit coronary arteries is of benefit, and previous randomized trials comparing the procedures did not look at patients with cardiogenic shock, Holger Thiele, MD, reported at the Transcatheter Cardiovascular Therapeutics annual educational meeting.

Bruce Jancin/Frontline Medical News

In patients with acute myocardial infarction and multivessel coronary artery disease with cardiogenic shock, 30-day rates of death and renal-replacement therapy were lower when patients underwent percutaneous coronary intervention (PCI) of the culprit lesion as opposed to multivessel PCI.

The difference appeared to be driven by mortality, as the renal endpoint alone was not significant.

As many as 80% of patients with cardiogenic shock also present with multivessel coronary artery disease, and this is associated with worse mortality. It is unclear whether immediate PCI of clinically important stenoses of major nonculprit coronary arteries is of benefit, and previous randomized trials comparing the procedures did not look at patients with cardiogenic shock, Holger Thiele, MD, reported at the Transcatheter Cardiovascular Therapeutics annual educational meeting.

Bruce Jancin/Frontline Medical News

SAN DIEGO – Epilepsy is a common condition, but many people live in areas too poor or underserved to benefit from electroencephalogram (EEG) testing to confirm a diagnosis. Modern technology may be changing that. Smartphones wirelessly linked to headsets can collect EEG data and potentially serve as an alternate platform for diagnosis of epilepsy.

To test the efficacy of one such system, Farrah Mateen, MD, PhD, a neurologist at Massachusetts General Hospital, Boston, conducted a study in the remote, mountainous Kingdom of Bhutan, which lies between India and China. Her group compared the signals between a smartphone EEG and standard EEG.

The sensitivity was low, at around 40%, but the device’s specificity was 90%-95%. For now, the device performs better as a confirmatory test than as a screening device, but the researchers hope to adjust the lead location to improve sensitivity.

The headset used was designed for use by video gamers, and at a cost of less than $300, it represents a low-cost entry into portable EEG.

Dr. Mateen discussed the smartphone EEG study in a video interview at the annual meeting of the American Neurological Association.

SAN DIEGO – Epilepsy is a common condition, but many people live in areas too poor or underserved to benefit from electroencephalogram (EEG) testing to confirm a diagnosis. Modern technology may be changing that. Smartphones wirelessly linked to headsets can collect EEG data and potentially serve as an alternate platform for diagnosis of epilepsy.

To test the efficacy of one such system, Farrah Mateen, MD, PhD, a neurologist at Massachusetts General Hospital, Boston, conducted a study in the remote, mountainous Kingdom of Bhutan, which lies between India and China. Her group compared the signals between a smartphone EEG and standard EEG.

The sensitivity was low, at around 40%, but the device’s specificity was 90%-95%. For now, the device performs better as a confirmatory test than as a screening device, but the researchers hope to adjust the lead location to improve sensitivity.

The headset used was designed for use by video gamers, and at a cost of less than $300, it represents a low-cost entry into portable EEG.

Dr. Mateen discussed the smartphone EEG study in a video interview at the annual meeting of the American Neurological Association.

SAN DIEGO – Epilepsy is a common condition, but many people live in areas too poor or underserved to benefit from electroencephalogram (EEG) testing to confirm a diagnosis. Modern technology may be changing that. Smartphones wirelessly linked to headsets can collect EEG data and potentially serve as an alternate platform for diagnosis of epilepsy.

To test the efficacy of one such system, Farrah Mateen, MD, PhD, a neurologist at Massachusetts General Hospital, Boston, conducted a study in the remote, mountainous Kingdom of Bhutan, which lies between India and China. Her group compared the signals between a smartphone EEG and standard EEG.

The sensitivity was low, at around 40%, but the device’s specificity was 90%-95%. For now, the device performs better as a confirmatory test than as a screening device, but the researchers hope to adjust the lead location to improve sensitivity.

The headset used was designed for use by video gamers, and at a cost of less than $300, it represents a low-cost entry into portable EEG.

Dr. Mateen discussed the smartphone EEG study in a video interview at the annual meeting of the American Neurological Association.