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New ESC guidelines for cutting CV risk in noncardiac surgery
The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.
They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.
Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.
The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).
It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.
In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:
First, recommendations for preoperative ECG and biomarkers are more specific, he noted.
The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:
- It is recommended to obtain a preoperative 12-lead ECG (class I).
- It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
- It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).
However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).
Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.
Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”
Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”
“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
More preoperative recommendations
In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.
If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).
Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).
“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “
“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
Patients with specific types of CVD
Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.
Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”
“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”
Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).
Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).
Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”
Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”
Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
Postoperative cardiovascular complications
The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.
“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”
“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.
The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”
Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.
“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”
In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).
Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.
The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.
The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
Noncardiac surgery risk categories
The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:
- Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
- Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
- High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.
The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.
A version of this article first appeared on Medscape.com.
The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.
They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.
Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.
The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).
It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.
In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:
First, recommendations for preoperative ECG and biomarkers are more specific, he noted.
The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:
- It is recommended to obtain a preoperative 12-lead ECG (class I).
- It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
- It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).
However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).
Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.
Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”
Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”
“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
More preoperative recommendations
In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.
If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).
Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).
“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “
“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
Patients with specific types of CVD
Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.
Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”
“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”
Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).
Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).
Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”
Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”
Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
Postoperative cardiovascular complications
The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.
“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”
“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.
The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”
Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.
“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”
In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).
Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.
The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.
The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
Noncardiac surgery risk categories
The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:
- Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
- Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
- High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.
The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.
A version of this article first appeared on Medscape.com.
The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.
They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.
Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.
The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).
It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.
In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:
First, recommendations for preoperative ECG and biomarkers are more specific, he noted.
The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:
- It is recommended to obtain a preoperative 12-lead ECG (class I).
- It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
- It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).
However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).
Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.
Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”
Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”
“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
More preoperative recommendations
In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.
If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).
Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).
“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “
“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
Patients with specific types of CVD
Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.
Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”
“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”
Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).
Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).
Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”
Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”
Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
Postoperative cardiovascular complications
The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.
“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”
“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.
The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”
Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.
“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”
In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).
Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.
The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.
The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
Noncardiac surgery risk categories
The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:
- Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
- Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
- High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.
The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.
A version of this article first appeared on Medscape.com.
FROM ESC CONGRESS 2022
Add AFib to noncardiac surgery risk evaluation: New support
Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.
But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.
Indeed, AFib emerged as a significant, independent risk factor for a number of bad postoperative outcomes. Mortality within a month of the procedure climbed about 30% for patients with AFib before the noncardiac surgery. Their 30-day risks for stroke and for heart failure hospitalization went up similarly.
The addition of AFib to the RCRI significantly improved its ability to discriminate 30-day postoperative risk levels regardless of age, sex, and type of noncardiac surgery, Amgad Mentias, MD, Cleveland Clinic, told this news organization. And “it was able to correctly up-classify patients to high risk, if AFib was there, and it was able to down-classify some patients to lower risk if it wasn’t there.”
“I think [the findings] are convincing evidence that atrial fib should at least be part of the thought process for the surgical team and the medical team taking care of the patient,” said Dr. Mentias, who is senior author on the study published in the Journal of the American College of Cardiology, with lead author Sameer Prasada, MD, also of the Cleveland Clinic.
The results “call for incorporating AFib as a risk factor in perioperative risk scores for cardiovascular morbidity and mortality,” the published report states.
Supraventricular arrhythmias had been part of the Goldman Risk Index once widely used preoperatively to assess cardiac risk before practice adopted the RCRI in the past decade, observe Anne B. Curtis, MD, and Sai Krishna C. Korada, MD, University at Buffalo, New York, in an accompanying editorial.
The current findings “demonstrate improved prediction of adverse postsurgical outcomes” from supplementing the RCRI with AFib, they write. Given associations between preexisting AFib and serious cardiac events, “it is time to ‘re-revise’ the RCRI and acknowledge the importance of AFib in predicting adverse outcomes” after noncardiac surgery.
The new findings, however, aren’t all straightforward. In one result that remains a bit of a head-scratcher, postoperative risk of myocardial infarction (MI) in patients with preexisting AFib went in the opposite direction of risk for death and other CV outcomes, falling by almost 20%.
That is “hard to explain with the available data,” the report states, but “the use of anticoagulation, whether oral or parenteral (as a bridge therapy in the perioperative period), is a plausible explanation” given the frequent role of thrombosis in triggering MIs.
Consistent with such a mechanism, the group argues, the MI risk reduction was seen primarily among patients with AFib and a CHA2DS2-VASc score of 2 or higher – that is, those at highest risk for stroke and therefore most likely to be on oral anticoagulation. The MI risk reduction wasn’t seen in such patients with a CHA2DS2-VASc score of 0 or 1.
“I think that’s part of the explanation, that anticoagulation can reduce risk of MI. But it’s not the whole explanation,” Dr. Mentias said in an interview. If it were the sole mechanism, he said, then the same oral anticoagulation that protected against MI should have also cut the postoperative stroke risk. Yet that risk climbed 40% among patients with preexisting AFib.
The analysis started with 8.6 million Medicare patients with planned noncardiac surgery, seen from 2015 to 2019, of whom 16.4% had preexisting AFib. Propensity matching for demographics, urgency and type of surgery, CHA2DS2-VASc score, and RCRI index created two cohorts for comparison: 1.13 million patients with and 1.92 million without preexisting AFib.
Preexisting AFib was associated with a higher 30-day risk for death from any cause, the primary endpoint being 8.3% versus 5.8% for those without such AFib (P < .001), for an odds ratio of 1.31 (95% confidence interval, 1.30-1.32).
Corresponding 30-day ORs for other events, all significant at P < .001, were:
- 1.31 (95% CI, 1.30-1.33) for heart failure
- 1.40 (95% CI, 1.37-1.43) for stroke
- 1.59 (95% CI, 1.43-1.75) for systemic embolism
- 1.14 (95% CI, 1.13-1.16) for major bleeding
- 0.81 (95% CI, 0.79-0.82) for MI
Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).
The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.
For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.
“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”
Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.
But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.
Indeed, AFib emerged as a significant, independent risk factor for a number of bad postoperative outcomes. Mortality within a month of the procedure climbed about 30% for patients with AFib before the noncardiac surgery. Their 30-day risks for stroke and for heart failure hospitalization went up similarly.
The addition of AFib to the RCRI significantly improved its ability to discriminate 30-day postoperative risk levels regardless of age, sex, and type of noncardiac surgery, Amgad Mentias, MD, Cleveland Clinic, told this news organization. And “it was able to correctly up-classify patients to high risk, if AFib was there, and it was able to down-classify some patients to lower risk if it wasn’t there.”
“I think [the findings] are convincing evidence that atrial fib should at least be part of the thought process for the surgical team and the medical team taking care of the patient,” said Dr. Mentias, who is senior author on the study published in the Journal of the American College of Cardiology, with lead author Sameer Prasada, MD, also of the Cleveland Clinic.
The results “call for incorporating AFib as a risk factor in perioperative risk scores for cardiovascular morbidity and mortality,” the published report states.
Supraventricular arrhythmias had been part of the Goldman Risk Index once widely used preoperatively to assess cardiac risk before practice adopted the RCRI in the past decade, observe Anne B. Curtis, MD, and Sai Krishna C. Korada, MD, University at Buffalo, New York, in an accompanying editorial.
The current findings “demonstrate improved prediction of adverse postsurgical outcomes” from supplementing the RCRI with AFib, they write. Given associations between preexisting AFib and serious cardiac events, “it is time to ‘re-revise’ the RCRI and acknowledge the importance of AFib in predicting adverse outcomes” after noncardiac surgery.
The new findings, however, aren’t all straightforward. In one result that remains a bit of a head-scratcher, postoperative risk of myocardial infarction (MI) in patients with preexisting AFib went in the opposite direction of risk for death and other CV outcomes, falling by almost 20%.
That is “hard to explain with the available data,” the report states, but “the use of anticoagulation, whether oral or parenteral (as a bridge therapy in the perioperative period), is a plausible explanation” given the frequent role of thrombosis in triggering MIs.
Consistent with such a mechanism, the group argues, the MI risk reduction was seen primarily among patients with AFib and a CHA2DS2-VASc score of 2 or higher – that is, those at highest risk for stroke and therefore most likely to be on oral anticoagulation. The MI risk reduction wasn’t seen in such patients with a CHA2DS2-VASc score of 0 or 1.
“I think that’s part of the explanation, that anticoagulation can reduce risk of MI. But it’s not the whole explanation,” Dr. Mentias said in an interview. If it were the sole mechanism, he said, then the same oral anticoagulation that protected against MI should have also cut the postoperative stroke risk. Yet that risk climbed 40% among patients with preexisting AFib.
The analysis started with 8.6 million Medicare patients with planned noncardiac surgery, seen from 2015 to 2019, of whom 16.4% had preexisting AFib. Propensity matching for demographics, urgency and type of surgery, CHA2DS2-VASc score, and RCRI index created two cohorts for comparison: 1.13 million patients with and 1.92 million without preexisting AFib.
Preexisting AFib was associated with a higher 30-day risk for death from any cause, the primary endpoint being 8.3% versus 5.8% for those without such AFib (P < .001), for an odds ratio of 1.31 (95% confidence interval, 1.30-1.32).
Corresponding 30-day ORs for other events, all significant at P < .001, were:
- 1.31 (95% CI, 1.30-1.33) for heart failure
- 1.40 (95% CI, 1.37-1.43) for stroke
- 1.59 (95% CI, 1.43-1.75) for systemic embolism
- 1.14 (95% CI, 1.13-1.16) for major bleeding
- 0.81 (95% CI, 0.79-0.82) for MI
Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).
The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.
For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.
“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”
Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.
But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.
Indeed, AFib emerged as a significant, independent risk factor for a number of bad postoperative outcomes. Mortality within a month of the procedure climbed about 30% for patients with AFib before the noncardiac surgery. Their 30-day risks for stroke and for heart failure hospitalization went up similarly.
The addition of AFib to the RCRI significantly improved its ability to discriminate 30-day postoperative risk levels regardless of age, sex, and type of noncardiac surgery, Amgad Mentias, MD, Cleveland Clinic, told this news organization. And “it was able to correctly up-classify patients to high risk, if AFib was there, and it was able to down-classify some patients to lower risk if it wasn’t there.”
“I think [the findings] are convincing evidence that atrial fib should at least be part of the thought process for the surgical team and the medical team taking care of the patient,” said Dr. Mentias, who is senior author on the study published in the Journal of the American College of Cardiology, with lead author Sameer Prasada, MD, also of the Cleveland Clinic.
The results “call for incorporating AFib as a risk factor in perioperative risk scores for cardiovascular morbidity and mortality,” the published report states.
Supraventricular arrhythmias had been part of the Goldman Risk Index once widely used preoperatively to assess cardiac risk before practice adopted the RCRI in the past decade, observe Anne B. Curtis, MD, and Sai Krishna C. Korada, MD, University at Buffalo, New York, in an accompanying editorial.
The current findings “demonstrate improved prediction of adverse postsurgical outcomes” from supplementing the RCRI with AFib, they write. Given associations between preexisting AFib and serious cardiac events, “it is time to ‘re-revise’ the RCRI and acknowledge the importance of AFib in predicting adverse outcomes” after noncardiac surgery.
The new findings, however, aren’t all straightforward. In one result that remains a bit of a head-scratcher, postoperative risk of myocardial infarction (MI) in patients with preexisting AFib went in the opposite direction of risk for death and other CV outcomes, falling by almost 20%.
That is “hard to explain with the available data,” the report states, but “the use of anticoagulation, whether oral or parenteral (as a bridge therapy in the perioperative period), is a plausible explanation” given the frequent role of thrombosis in triggering MIs.
Consistent with such a mechanism, the group argues, the MI risk reduction was seen primarily among patients with AFib and a CHA2DS2-VASc score of 2 or higher – that is, those at highest risk for stroke and therefore most likely to be on oral anticoagulation. The MI risk reduction wasn’t seen in such patients with a CHA2DS2-VASc score of 0 or 1.
“I think that’s part of the explanation, that anticoagulation can reduce risk of MI. But it’s not the whole explanation,” Dr. Mentias said in an interview. If it were the sole mechanism, he said, then the same oral anticoagulation that protected against MI should have also cut the postoperative stroke risk. Yet that risk climbed 40% among patients with preexisting AFib.
The analysis started with 8.6 million Medicare patients with planned noncardiac surgery, seen from 2015 to 2019, of whom 16.4% had preexisting AFib. Propensity matching for demographics, urgency and type of surgery, CHA2DS2-VASc score, and RCRI index created two cohorts for comparison: 1.13 million patients with and 1.92 million without preexisting AFib.
Preexisting AFib was associated with a higher 30-day risk for death from any cause, the primary endpoint being 8.3% versus 5.8% for those without such AFib (P < .001), for an odds ratio of 1.31 (95% confidence interval, 1.30-1.32).
Corresponding 30-day ORs for other events, all significant at P < .001, were:
- 1.31 (95% CI, 1.30-1.33) for heart failure
- 1.40 (95% CI, 1.37-1.43) for stroke
- 1.59 (95% CI, 1.43-1.75) for systemic embolism
- 1.14 (95% CI, 1.13-1.16) for major bleeding
- 0.81 (95% CI, 0.79-0.82) for MI
Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).
The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.
For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.
“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”
Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Laparoscopy linked to lower surgical infections for hernia surgery
BALTIMORE – A large retrospective study found that even though the laparoscopic group had higher body mass index and rates of other key comorbidities, according to results reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
“In patients with obesity, even though our laparoscopic umbilical hernia repair [UHR] group had an overall higher BMI; higher rates of diabetes, hypertension, and current smoking status; and longer operative times, they experienced decreased postoperative wound complications, compared to the open-repair group,” said Kristen Williams, MD, of TriHealth in Cincinnati.
The retrospective cohort study evaluated 12,026 adult patients with a BMI of more than 30 kg/m2 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had UHR in 2016. Almost four times as many patients had open rather than laparoscopic surgery (9,695 vs. 2,331, respectively)
Dr. Williams noted that two previous studies reported lower wound infection rates after laparoscopic hernia repair in patients with obesity: an analysis of ventral, not just umbilical, hernia repair based on the NSQIP database from 2009-2012 (Am J Surg. 2015;210:1029-30) and a single-institution retrospective chart review from 2003-2009 of patients who had umbilical hernia repair (Am J Surg. 2013;205:231-6). “In our study we wanted to compare the rate of postoperative complications after laparoscopic vs. open umbilical hernia repairs in patients with obesity based on NSQIP review,” she said.
The rate of composite surgical-site infections in the open group was 1.9% vs. 1.1% in the laparoscopic group (P less than .01), Dr. Williams noted. “SSI was statistically significantly higher in the open-repair group, and there was a trend toward higher deep SSI in the open group [0.3% vs. 0.1%; P = .147],” she said. Laparoscopic patients had significantly higher rates of postoperative pneumonia (0.4% vs 0.1%; P = .012), but Dr. Williams noted this was only significant in the non–elective surgery group. Operative times were significantly longer in the laparoscopic repair group (70 vs. 44 minutes). “The literature shows that longer operative times are associated with higher rates of SSI,” Dr. Williams added. “However our laparoscopic group still had lower rates of composite SSI.”
“Logistic regression was utilized and found that morbidity, defined as superficial, deep, and organ-space SSIs, was significantly increased in the open-repair group,” Dr. Williams said.
A higher percentage of patients in the laparoscopic group were women than in the open group (29.4% vs. 24.4%; P less than .001). The laparoscopic group had statistically significant higher average BMI (37.5 vs. 36.1; P less than .001) and higher rates of smoking (18.6% vs. 16.5%; P = .018), diabetes (18.4% vs. 15.8%; P = .002), and hypertension (47.5% vs. 43.8%; P = .001) than the open group.
The study also analyzed outcomes by BMI class. “As BMI class increased, superficial SSI, deep SSI, return-to-OR rates, postoperative pneumonia rates, and composite SSI increased in the open-repair group, indicating that higher BMI is associated with higher rates of complications in the open-repair group,” Dr. Williams said. Likewise, as obesity class increased, so did operative times in both the open and laparoscopic groups, she added.
She also noted that this study reported a significant increase in the proportion of laparoscopic UHRs than did a retrospective cohort study of 2009 and 2010 NSQIP files of UHR (Surg Endosc. 2014;28:741-6), 19.4% in this study versus 10.5% in that one.
Dr. Williams had no financial relationships to disclose.
SOURCE: Williams K et al. SAGES 2019, Abstract S099.
BALTIMORE – A large retrospective study found that even though the laparoscopic group had higher body mass index and rates of other key comorbidities, according to results reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
“In patients with obesity, even though our laparoscopic umbilical hernia repair [UHR] group had an overall higher BMI; higher rates of diabetes, hypertension, and current smoking status; and longer operative times, they experienced decreased postoperative wound complications, compared to the open-repair group,” said Kristen Williams, MD, of TriHealth in Cincinnati.
The retrospective cohort study evaluated 12,026 adult patients with a BMI of more than 30 kg/m2 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had UHR in 2016. Almost four times as many patients had open rather than laparoscopic surgery (9,695 vs. 2,331, respectively)
Dr. Williams noted that two previous studies reported lower wound infection rates after laparoscopic hernia repair in patients with obesity: an analysis of ventral, not just umbilical, hernia repair based on the NSQIP database from 2009-2012 (Am J Surg. 2015;210:1029-30) and a single-institution retrospective chart review from 2003-2009 of patients who had umbilical hernia repair (Am J Surg. 2013;205:231-6). “In our study we wanted to compare the rate of postoperative complications after laparoscopic vs. open umbilical hernia repairs in patients with obesity based on NSQIP review,” she said.
The rate of composite surgical-site infections in the open group was 1.9% vs. 1.1% in the laparoscopic group (P less than .01), Dr. Williams noted. “SSI was statistically significantly higher in the open-repair group, and there was a trend toward higher deep SSI in the open group [0.3% vs. 0.1%; P = .147],” she said. Laparoscopic patients had significantly higher rates of postoperative pneumonia (0.4% vs 0.1%; P = .012), but Dr. Williams noted this was only significant in the non–elective surgery group. Operative times were significantly longer in the laparoscopic repair group (70 vs. 44 minutes). “The literature shows that longer operative times are associated with higher rates of SSI,” Dr. Williams added. “However our laparoscopic group still had lower rates of composite SSI.”
“Logistic regression was utilized and found that morbidity, defined as superficial, deep, and organ-space SSIs, was significantly increased in the open-repair group,” Dr. Williams said.
A higher percentage of patients in the laparoscopic group were women than in the open group (29.4% vs. 24.4%; P less than .001). The laparoscopic group had statistically significant higher average BMI (37.5 vs. 36.1; P less than .001) and higher rates of smoking (18.6% vs. 16.5%; P = .018), diabetes (18.4% vs. 15.8%; P = .002), and hypertension (47.5% vs. 43.8%; P = .001) than the open group.
The study also analyzed outcomes by BMI class. “As BMI class increased, superficial SSI, deep SSI, return-to-OR rates, postoperative pneumonia rates, and composite SSI increased in the open-repair group, indicating that higher BMI is associated with higher rates of complications in the open-repair group,” Dr. Williams said. Likewise, as obesity class increased, so did operative times in both the open and laparoscopic groups, she added.
She also noted that this study reported a significant increase in the proportion of laparoscopic UHRs than did a retrospective cohort study of 2009 and 2010 NSQIP files of UHR (Surg Endosc. 2014;28:741-6), 19.4% in this study versus 10.5% in that one.
Dr. Williams had no financial relationships to disclose.
SOURCE: Williams K et al. SAGES 2019, Abstract S099.
BALTIMORE – A large retrospective study found that even though the laparoscopic group had higher body mass index and rates of other key comorbidities, according to results reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
“In patients with obesity, even though our laparoscopic umbilical hernia repair [UHR] group had an overall higher BMI; higher rates of diabetes, hypertension, and current smoking status; and longer operative times, they experienced decreased postoperative wound complications, compared to the open-repair group,” said Kristen Williams, MD, of TriHealth in Cincinnati.
The retrospective cohort study evaluated 12,026 adult patients with a BMI of more than 30 kg/m2 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had UHR in 2016. Almost four times as many patients had open rather than laparoscopic surgery (9,695 vs. 2,331, respectively)
Dr. Williams noted that two previous studies reported lower wound infection rates after laparoscopic hernia repair in patients with obesity: an analysis of ventral, not just umbilical, hernia repair based on the NSQIP database from 2009-2012 (Am J Surg. 2015;210:1029-30) and a single-institution retrospective chart review from 2003-2009 of patients who had umbilical hernia repair (Am J Surg. 2013;205:231-6). “In our study we wanted to compare the rate of postoperative complications after laparoscopic vs. open umbilical hernia repairs in patients with obesity based on NSQIP review,” she said.
The rate of composite surgical-site infections in the open group was 1.9% vs. 1.1% in the laparoscopic group (P less than .01), Dr. Williams noted. “SSI was statistically significantly higher in the open-repair group, and there was a trend toward higher deep SSI in the open group [0.3% vs. 0.1%; P = .147],” she said. Laparoscopic patients had significantly higher rates of postoperative pneumonia (0.4% vs 0.1%; P = .012), but Dr. Williams noted this was only significant in the non–elective surgery group. Operative times were significantly longer in the laparoscopic repair group (70 vs. 44 minutes). “The literature shows that longer operative times are associated with higher rates of SSI,” Dr. Williams added. “However our laparoscopic group still had lower rates of composite SSI.”
“Logistic regression was utilized and found that morbidity, defined as superficial, deep, and organ-space SSIs, was significantly increased in the open-repair group,” Dr. Williams said.
A higher percentage of patients in the laparoscopic group were women than in the open group (29.4% vs. 24.4%; P less than .001). The laparoscopic group had statistically significant higher average BMI (37.5 vs. 36.1; P less than .001) and higher rates of smoking (18.6% vs. 16.5%; P = .018), diabetes (18.4% vs. 15.8%; P = .002), and hypertension (47.5% vs. 43.8%; P = .001) than the open group.
The study also analyzed outcomes by BMI class. “As BMI class increased, superficial SSI, deep SSI, return-to-OR rates, postoperative pneumonia rates, and composite SSI increased in the open-repair group, indicating that higher BMI is associated with higher rates of complications in the open-repair group,” Dr. Williams said. Likewise, as obesity class increased, so did operative times in both the open and laparoscopic groups, she added.
She also noted that this study reported a significant increase in the proportion of laparoscopic UHRs than did a retrospective cohort study of 2009 and 2010 NSQIP files of UHR (Surg Endosc. 2014;28:741-6), 19.4% in this study versus 10.5% in that one.
Dr. Williams had no financial relationships to disclose.
SOURCE: Williams K et al. SAGES 2019, Abstract S099.
REPORTING FROM SAGES 2019
Study identifies malpractice causes in hernia repair
BALTIMORE – An and intraoperative damage to surrounding structures was the leading reason for such lawsuits, according to research presented at the annual meeting of the American Gastrointestinal and Endoscopic Surgeons.
The purpose of the study was to identify leading causes of litigation for hernia repair as the volume of hernia repairs in the United States increases with a trend toward minimally invasive and robotic surgery, said Asad Choudhry, MBBS, of the State University of New York, Syracuse.“In terms of the hernia itself, inguinal hernia operations were found to be the most common hernia procedure that led to pursuance of litigation, and laparoscopy was the most common type of procedure rather than open in terms of patients pursuing litigation.”
The study sampled the WestLawNext legal database for medical malpractice abdominal wall procedures, and evaluated 430 cases of abdominopelvic wall hernias that fit the study criteria – inguinal, femoral, ventral, umbilical, parastomal, spigelian, obturator, epigastric, incisional, paraumbilical, and pantaloon hernias, Dr. Choudhry said. Hiatal, diaphragmatic, sciatic, gluteal, and lumbar hernias were excluded. He noted that abdominal wall hernia have been reported to be the second most common abdominopelvic procedure performed in the United States after C-section, with more than 1 million procedures done annually (Surg Clin N Am. 2003;83:1045-51).
While most malpractice hernia cases were decided in favor of the defendant surgeon, settlements and cases with a jury verdict in favor of the plaintiff were costly. Dr. Choudhry cited awards of $6.8 million, $12 million, and $3 million in specific hernia cases.
“In terms of the type of repair itself, elective operations were more common, and mesh was used in approximately 27% of cases in which there was a defendant verdict and 18% of cases in which there was a plaintiff verdict,” he said.
For inguinal hernia, 61% of cases were decided for the defendant surgeon. With regards to type of procedure, laparoscopic surgery resulted in defendant verdicts in 31% of cases versus 23% for the plaintiff, and open operations resulted in a ruling favoring the defendant surgeon in 26% versus 15% for the plaintiff. (The remainder were lap-converted-to-open operations, with 2% for the defendant and 1% for the plaintiff.)
Mortality was a key determinant of verdict, Dr. Choudhry added. “Cases with no mortality were more likely of having an outcome in favor of the defendant surgeon.”
The researchers also looked at litigation arising from the phase of care – before, during, or after surgery. “In the preoperative time setting, delay or failure to diagnose or manage a hernia was the leading cause of malpractice,” Dr. Choudhry said. “These cases were mainly emergent patients presenting to the emergency department where the intervention was not performed in a timely manner and leading to some form of complication.”
In the intraoperative period, damage to surrounding structures was by far the leading cause of malpractice, but incomplete procedure or improper surgical technique and use of improper surgical materials also were significant causes in this period. Postoperatively, failure to timely detect and/or repair a surgical complication was the most common cause of litigation. “However, it’s important to note that persistent pain, such as nerve entrapment syndrome, is also noted in the postoperative time period as a cause of litigation,” he added.
The study also evaluated injury severity in the context of a claim outcome. “Most claims where there was an insignificant or minor injury were decided for the defendant surgeon,” Dr. Choudhry said. “But as you start moving higher on the injury scale toward death, these cases were more likely to favor the plaintiff, and that’s correlative because patients tend to sue more when there’s a more significant complication, such as when there’s a death of a family member.” In cases involving death, 41% resulted in a verdict for the defendant surgery, 35% in a plaintiff verdict, and 23% in a settlement, whereas in cases involving insignificant temporary injury, 90% were ruled for the defendant surgeon, with none going to settlement.
The research also found another mitigating factor in malpractice lawsuits: the number of lawyers in a state. “We noted that specific states such as California, New York, Texas, and Florida were bound to have a higher number of lawsuits per population, and this was correlative with the number of lawyers practicing within that state,” Dr. Choudhry said. New York led the nation with 46 cases, followed by California with 42, Florida with 27 ,and Texas and Pennsylvania with 17 each.
Session moderator Heather Logghe, MD, of Jefferson Medical College, Philadelphia, questioned Dr. Choudhry on how surgeons can improve their informed consent process to protect against potential litigation.
“The most important thing we can do is document and explain the risk, benefits, and alternatives, and use an inclusive informed consent that will allow the patients to have a complete understanding of the procedure that is to be done and the complications that may result,” he said. This process needs to be tailored to individual hospital systems. “This may allow for better documentation, and it may not decrease the number of malpractice lawsuits but it may decrease the outcomes not in favor of physicians.”
The researchers also identified trends in the broader context of medical malpractice. Citing data from the National Practitioner Data Bank, Dr. Choudhry noted that malpractice payouts have been increasing since 2012 after a steady 9-year decline. In addition, general surgeons are at greater risk than all but two other types of specialists – neurosurgeons and thoracic-cardiovascular surgeons (N Engl J Med. 2011;365:629-36). “Fifteen percent of general surgeons will be facing malpractice claims annually across the United States. Physicians in high-legal-risk specialties, such as the surgical specialties, are 99% likely to face a claim over their careers.”
The next step for the researchers is to use malpractice insurance data to study medical liability on a larger scale and identify methods physicians can use to improve patient care and mitigate risk, Dr. Choudhry said.
Dr. Choudhry had no relevant financial relationships to disclose.
SOURCE: Choudhry A et al. SAGES 2109, Abstract S104.
BALTIMORE – An and intraoperative damage to surrounding structures was the leading reason for such lawsuits, according to research presented at the annual meeting of the American Gastrointestinal and Endoscopic Surgeons.
The purpose of the study was to identify leading causes of litigation for hernia repair as the volume of hernia repairs in the United States increases with a trend toward minimally invasive and robotic surgery, said Asad Choudhry, MBBS, of the State University of New York, Syracuse.“In terms of the hernia itself, inguinal hernia operations were found to be the most common hernia procedure that led to pursuance of litigation, and laparoscopy was the most common type of procedure rather than open in terms of patients pursuing litigation.”
The study sampled the WestLawNext legal database for medical malpractice abdominal wall procedures, and evaluated 430 cases of abdominopelvic wall hernias that fit the study criteria – inguinal, femoral, ventral, umbilical, parastomal, spigelian, obturator, epigastric, incisional, paraumbilical, and pantaloon hernias, Dr. Choudhry said. Hiatal, diaphragmatic, sciatic, gluteal, and lumbar hernias were excluded. He noted that abdominal wall hernia have been reported to be the second most common abdominopelvic procedure performed in the United States after C-section, with more than 1 million procedures done annually (Surg Clin N Am. 2003;83:1045-51).
While most malpractice hernia cases were decided in favor of the defendant surgeon, settlements and cases with a jury verdict in favor of the plaintiff were costly. Dr. Choudhry cited awards of $6.8 million, $12 million, and $3 million in specific hernia cases.
“In terms of the type of repair itself, elective operations were more common, and mesh was used in approximately 27% of cases in which there was a defendant verdict and 18% of cases in which there was a plaintiff verdict,” he said.
For inguinal hernia, 61% of cases were decided for the defendant surgeon. With regards to type of procedure, laparoscopic surgery resulted in defendant verdicts in 31% of cases versus 23% for the plaintiff, and open operations resulted in a ruling favoring the defendant surgeon in 26% versus 15% for the plaintiff. (The remainder were lap-converted-to-open operations, with 2% for the defendant and 1% for the plaintiff.)
Mortality was a key determinant of verdict, Dr. Choudhry added. “Cases with no mortality were more likely of having an outcome in favor of the defendant surgeon.”
The researchers also looked at litigation arising from the phase of care – before, during, or after surgery. “In the preoperative time setting, delay or failure to diagnose or manage a hernia was the leading cause of malpractice,” Dr. Choudhry said. “These cases were mainly emergent patients presenting to the emergency department where the intervention was not performed in a timely manner and leading to some form of complication.”
In the intraoperative period, damage to surrounding structures was by far the leading cause of malpractice, but incomplete procedure or improper surgical technique and use of improper surgical materials also were significant causes in this period. Postoperatively, failure to timely detect and/or repair a surgical complication was the most common cause of litigation. “However, it’s important to note that persistent pain, such as nerve entrapment syndrome, is also noted in the postoperative time period as a cause of litigation,” he added.
The study also evaluated injury severity in the context of a claim outcome. “Most claims where there was an insignificant or minor injury were decided for the defendant surgeon,” Dr. Choudhry said. “But as you start moving higher on the injury scale toward death, these cases were more likely to favor the plaintiff, and that’s correlative because patients tend to sue more when there’s a more significant complication, such as when there’s a death of a family member.” In cases involving death, 41% resulted in a verdict for the defendant surgery, 35% in a plaintiff verdict, and 23% in a settlement, whereas in cases involving insignificant temporary injury, 90% were ruled for the defendant surgeon, with none going to settlement.
The research also found another mitigating factor in malpractice lawsuits: the number of lawyers in a state. “We noted that specific states such as California, New York, Texas, and Florida were bound to have a higher number of lawsuits per population, and this was correlative with the number of lawyers practicing within that state,” Dr. Choudhry said. New York led the nation with 46 cases, followed by California with 42, Florida with 27 ,and Texas and Pennsylvania with 17 each.
Session moderator Heather Logghe, MD, of Jefferson Medical College, Philadelphia, questioned Dr. Choudhry on how surgeons can improve their informed consent process to protect against potential litigation.
“The most important thing we can do is document and explain the risk, benefits, and alternatives, and use an inclusive informed consent that will allow the patients to have a complete understanding of the procedure that is to be done and the complications that may result,” he said. This process needs to be tailored to individual hospital systems. “This may allow for better documentation, and it may not decrease the number of malpractice lawsuits but it may decrease the outcomes not in favor of physicians.”
The researchers also identified trends in the broader context of medical malpractice. Citing data from the National Practitioner Data Bank, Dr. Choudhry noted that malpractice payouts have been increasing since 2012 after a steady 9-year decline. In addition, general surgeons are at greater risk than all but two other types of specialists – neurosurgeons and thoracic-cardiovascular surgeons (N Engl J Med. 2011;365:629-36). “Fifteen percent of general surgeons will be facing malpractice claims annually across the United States. Physicians in high-legal-risk specialties, such as the surgical specialties, are 99% likely to face a claim over their careers.”
The next step for the researchers is to use malpractice insurance data to study medical liability on a larger scale and identify methods physicians can use to improve patient care and mitigate risk, Dr. Choudhry said.
Dr. Choudhry had no relevant financial relationships to disclose.
SOURCE: Choudhry A et al. SAGES 2109, Abstract S104.
BALTIMORE – An and intraoperative damage to surrounding structures was the leading reason for such lawsuits, according to research presented at the annual meeting of the American Gastrointestinal and Endoscopic Surgeons.
The purpose of the study was to identify leading causes of litigation for hernia repair as the volume of hernia repairs in the United States increases with a trend toward minimally invasive and robotic surgery, said Asad Choudhry, MBBS, of the State University of New York, Syracuse.“In terms of the hernia itself, inguinal hernia operations were found to be the most common hernia procedure that led to pursuance of litigation, and laparoscopy was the most common type of procedure rather than open in terms of patients pursuing litigation.”
The study sampled the WestLawNext legal database for medical malpractice abdominal wall procedures, and evaluated 430 cases of abdominopelvic wall hernias that fit the study criteria – inguinal, femoral, ventral, umbilical, parastomal, spigelian, obturator, epigastric, incisional, paraumbilical, and pantaloon hernias, Dr. Choudhry said. Hiatal, diaphragmatic, sciatic, gluteal, and lumbar hernias were excluded. He noted that abdominal wall hernia have been reported to be the second most common abdominopelvic procedure performed in the United States after C-section, with more than 1 million procedures done annually (Surg Clin N Am. 2003;83:1045-51).
While most malpractice hernia cases were decided in favor of the defendant surgeon, settlements and cases with a jury verdict in favor of the plaintiff were costly. Dr. Choudhry cited awards of $6.8 million, $12 million, and $3 million in specific hernia cases.
“In terms of the type of repair itself, elective operations were more common, and mesh was used in approximately 27% of cases in which there was a defendant verdict and 18% of cases in which there was a plaintiff verdict,” he said.
For inguinal hernia, 61% of cases were decided for the defendant surgeon. With regards to type of procedure, laparoscopic surgery resulted in defendant verdicts in 31% of cases versus 23% for the plaintiff, and open operations resulted in a ruling favoring the defendant surgeon in 26% versus 15% for the plaintiff. (The remainder were lap-converted-to-open operations, with 2% for the defendant and 1% for the plaintiff.)
Mortality was a key determinant of verdict, Dr. Choudhry added. “Cases with no mortality were more likely of having an outcome in favor of the defendant surgeon.”
The researchers also looked at litigation arising from the phase of care – before, during, or after surgery. “In the preoperative time setting, delay or failure to diagnose or manage a hernia was the leading cause of malpractice,” Dr. Choudhry said. “These cases were mainly emergent patients presenting to the emergency department where the intervention was not performed in a timely manner and leading to some form of complication.”
In the intraoperative period, damage to surrounding structures was by far the leading cause of malpractice, but incomplete procedure or improper surgical technique and use of improper surgical materials also were significant causes in this period. Postoperatively, failure to timely detect and/or repair a surgical complication was the most common cause of litigation. “However, it’s important to note that persistent pain, such as nerve entrapment syndrome, is also noted in the postoperative time period as a cause of litigation,” he added.
The study also evaluated injury severity in the context of a claim outcome. “Most claims where there was an insignificant or minor injury were decided for the defendant surgeon,” Dr. Choudhry said. “But as you start moving higher on the injury scale toward death, these cases were more likely to favor the plaintiff, and that’s correlative because patients tend to sue more when there’s a more significant complication, such as when there’s a death of a family member.” In cases involving death, 41% resulted in a verdict for the defendant surgery, 35% in a plaintiff verdict, and 23% in a settlement, whereas in cases involving insignificant temporary injury, 90% were ruled for the defendant surgeon, with none going to settlement.
The research also found another mitigating factor in malpractice lawsuits: the number of lawyers in a state. “We noted that specific states such as California, New York, Texas, and Florida were bound to have a higher number of lawsuits per population, and this was correlative with the number of lawyers practicing within that state,” Dr. Choudhry said. New York led the nation with 46 cases, followed by California with 42, Florida with 27 ,and Texas and Pennsylvania with 17 each.
Session moderator Heather Logghe, MD, of Jefferson Medical College, Philadelphia, questioned Dr. Choudhry on how surgeons can improve their informed consent process to protect against potential litigation.
“The most important thing we can do is document and explain the risk, benefits, and alternatives, and use an inclusive informed consent that will allow the patients to have a complete understanding of the procedure that is to be done and the complications that may result,” he said. This process needs to be tailored to individual hospital systems. “This may allow for better documentation, and it may not decrease the number of malpractice lawsuits but it may decrease the outcomes not in favor of physicians.”
The researchers also identified trends in the broader context of medical malpractice. Citing data from the National Practitioner Data Bank, Dr. Choudhry noted that malpractice payouts have been increasing since 2012 after a steady 9-year decline. In addition, general surgeons are at greater risk than all but two other types of specialists – neurosurgeons and thoracic-cardiovascular surgeons (N Engl J Med. 2011;365:629-36). “Fifteen percent of general surgeons will be facing malpractice claims annually across the United States. Physicians in high-legal-risk specialties, such as the surgical specialties, are 99% likely to face a claim over their careers.”
The next step for the researchers is to use malpractice insurance data to study medical liability on a larger scale and identify methods physicians can use to improve patient care and mitigate risk, Dr. Choudhry said.
Dr. Choudhry had no relevant financial relationships to disclose.
SOURCE: Choudhry A et al. SAGES 2109, Abstract S104.
REPORTING FROM SAGES 2019
Robotic surgery offers minimally invasive approach to complex patients
LAS VEGAS – Colorectal surgeon Jamie Cannon, MD, doesn’t think there’s a rivalry between laparoscopic surgery and robotic surgery. Instead, she told colleagues, they should be seen as parts of the same whole: “Robotics is laparoscopy. It’s just a tool that allows us to do laparoscopic surgery better.”
Specifically, robotic surgery deserves a prominent place in treatment for rectal cancer, Dr. Cannon, associate professor of surgery at the University of Alabama at Birmingham, said in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We can reduce the conversion rate and offer more complex patients a minimally invasive operation,” she said.
Dr. Cannon listed these benefits of robotic surgery:
• Better cameras offer 3-D visualization.
• A stable operating platform provides tremor control.
• Instruments are fully articulated.
• The ability to perform fine dissection and complex suturing in confined spaces is enhanced.
• Ergonomics are improved.
“From a surgeon’s standpoint, it’s a lot more fun and a lot more comfortable,” she said. “You’re sitting there rather than straining your neck and arms to accomplish something difficult.”
Statistics show that robotics is gaining on open surgery in anterior rectal resection procedures while laparoscopy remains flat, she noted. In 2008, she said, the percentages for open, laparoscopic and robotic procedures were 81%, 18% and 1%, respectively. In 2015, they were 60%, 20% and 19%, respectively.
According to Dr. Cannon, other benefits of robotic surgery in rectal resections include better outcomes in difficult patients and lower conversion rates.
A 2017 prospective, randomized study did not show a difference between laparoscopic and robotic approaches to conversion rates in rectal resection, she noted (JAMA. 2017;318[16]:1569-80).
However, she said, a newer study presented at the Academic Surgical Congress in 2018 did show a major difference, with a conversion rate of 17% in laparoscopic procedures (n = 128) and 1% in robotic procedures (n = 92, P less than .05). Conversion rates in obese patients were similar.
In regard to obese patients, “we know they don’t do well,” Dr. Cannon said. “One thing we don’t always talk about is the impact on surgeons. These cases are very difficult to do.” Robotic technology allows surgeons to “make up for the challenges you experience laparoscopically” in these procedures, she said.
Robotics can be helpful because they allow surgeons to offer minimally invasive surgery to patients who pose challenges because of morbid obesity, inflammatory conditions such as Crohn’s disease and enteric fistulas, and histories of multiple previous surgeries, she added.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Cannon disclosed serving as an instructor for Intuitive Surgical.
LAS VEGAS – Colorectal surgeon Jamie Cannon, MD, doesn’t think there’s a rivalry between laparoscopic surgery and robotic surgery. Instead, she told colleagues, they should be seen as parts of the same whole: “Robotics is laparoscopy. It’s just a tool that allows us to do laparoscopic surgery better.”
Specifically, robotic surgery deserves a prominent place in treatment for rectal cancer, Dr. Cannon, associate professor of surgery at the University of Alabama at Birmingham, said in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We can reduce the conversion rate and offer more complex patients a minimally invasive operation,” she said.
Dr. Cannon listed these benefits of robotic surgery:
• Better cameras offer 3-D visualization.
• A stable operating platform provides tremor control.
• Instruments are fully articulated.
• The ability to perform fine dissection and complex suturing in confined spaces is enhanced.
• Ergonomics are improved.
“From a surgeon’s standpoint, it’s a lot more fun and a lot more comfortable,” she said. “You’re sitting there rather than straining your neck and arms to accomplish something difficult.”
Statistics show that robotics is gaining on open surgery in anterior rectal resection procedures while laparoscopy remains flat, she noted. In 2008, she said, the percentages for open, laparoscopic and robotic procedures were 81%, 18% and 1%, respectively. In 2015, they were 60%, 20% and 19%, respectively.
According to Dr. Cannon, other benefits of robotic surgery in rectal resections include better outcomes in difficult patients and lower conversion rates.
A 2017 prospective, randomized study did not show a difference between laparoscopic and robotic approaches to conversion rates in rectal resection, she noted (JAMA. 2017;318[16]:1569-80).
However, she said, a newer study presented at the Academic Surgical Congress in 2018 did show a major difference, with a conversion rate of 17% in laparoscopic procedures (n = 128) and 1% in robotic procedures (n = 92, P less than .05). Conversion rates in obese patients were similar.
In regard to obese patients, “we know they don’t do well,” Dr. Cannon said. “One thing we don’t always talk about is the impact on surgeons. These cases are very difficult to do.” Robotic technology allows surgeons to “make up for the challenges you experience laparoscopically” in these procedures, she said.
Robotics can be helpful because they allow surgeons to offer minimally invasive surgery to patients who pose challenges because of morbid obesity, inflammatory conditions such as Crohn’s disease and enteric fistulas, and histories of multiple previous surgeries, she added.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Cannon disclosed serving as an instructor for Intuitive Surgical.
LAS VEGAS – Colorectal surgeon Jamie Cannon, MD, doesn’t think there’s a rivalry between laparoscopic surgery and robotic surgery. Instead, she told colleagues, they should be seen as parts of the same whole: “Robotics is laparoscopy. It’s just a tool that allows us to do laparoscopic surgery better.”
Specifically, robotic surgery deserves a prominent place in treatment for rectal cancer, Dr. Cannon, associate professor of surgery at the University of Alabama at Birmingham, said in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We can reduce the conversion rate and offer more complex patients a minimally invasive operation,” she said.
Dr. Cannon listed these benefits of robotic surgery:
• Better cameras offer 3-D visualization.
• A stable operating platform provides tremor control.
• Instruments are fully articulated.
• The ability to perform fine dissection and complex suturing in confined spaces is enhanced.
• Ergonomics are improved.
“From a surgeon’s standpoint, it’s a lot more fun and a lot more comfortable,” she said. “You’re sitting there rather than straining your neck and arms to accomplish something difficult.”
Statistics show that robotics is gaining on open surgery in anterior rectal resection procedures while laparoscopy remains flat, she noted. In 2008, she said, the percentages for open, laparoscopic and robotic procedures were 81%, 18% and 1%, respectively. In 2015, they were 60%, 20% and 19%, respectively.
According to Dr. Cannon, other benefits of robotic surgery in rectal resections include better outcomes in difficult patients and lower conversion rates.
A 2017 prospective, randomized study did not show a difference between laparoscopic and robotic approaches to conversion rates in rectal resection, she noted (JAMA. 2017;318[16]:1569-80).
However, she said, a newer study presented at the Academic Surgical Congress in 2018 did show a major difference, with a conversion rate of 17% in laparoscopic procedures (n = 128) and 1% in robotic procedures (n = 92, P less than .05). Conversion rates in obese patients were similar.
In regard to obese patients, “we know they don’t do well,” Dr. Cannon said. “One thing we don’t always talk about is the impact on surgeons. These cases are very difficult to do.” Robotic technology allows surgeons to “make up for the challenges you experience laparoscopically” in these procedures, she said.
Robotics can be helpful because they allow surgeons to offer minimally invasive surgery to patients who pose challenges because of morbid obesity, inflammatory conditions such as Crohn’s disease and enteric fistulas, and histories of multiple previous surgeries, she added.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Cannon disclosed serving as an instructor for Intuitive Surgical.
REPORTING FROM MISS
Anti-mesh trend may be felt by surgeons doing hernia repairs
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
REPORTING FROM MISS
Stop-smoking rule before hernia repairs: Time for a rethink?
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
REPORTING FROM MISS
CT may predict complications after complex ventral hernia repair
Information obtained from computed tomography (CT) scans may help predict reherniation and surgical site infection (SSI) in patients who had complex ventral hernia repair with the component separation technique (CST), according to findings published in Hernia.
In a study of 65 adults who had a CT performed before CST, visceral fat volume was a significant predictor of reherniation (P = .025, odds ratio 1.65), reported Harm Winters of the department of plastic and reconstructive surgery at Radboud University Medical Center, Nijmegen, the Netherlands, and coauthors.
Patients were 18-75 years of age, and had complex ventral hernia repair via CST between 2000 and 2013. Patients were excluded if the CT scan was performed earlier than 6 months before hernia repair, or if the scan did not cover the full abdomen.
Visceral fat volume, subcutaneous fat volume, loss of domain, rectus thickness and width, abdominal volume, hernia sac volume, total fat volume, sagittal distance, and waist circumference were measured. Mesh reinforcement during surgery was used in 45 patients (69.2%), the authors noted.
Hernia sac volume and subcutaneous fat volume per 1,000 cm3 were significant predictors of surgical site infection (P = .020, OR 2.10 and P = .034, OR 0.26, respectively).
“These findings suggest that CT measurements are a valuable tool for preoperative risk assessment in patients undergoing complex ventral hernia repair using the CST,” the researchers wrote. Future trials should “further identify the role of these CT scan-derived body morphometrics for patient-tailored risk assessment,” they concluded.
No conflicts of interest were reported.
SOURCE: Winters H et al. Hernia. 2019 Mar 7. doi: 10.1007/s10029-019-01899-8.
Information obtained from computed tomography (CT) scans may help predict reherniation and surgical site infection (SSI) in patients who had complex ventral hernia repair with the component separation technique (CST), according to findings published in Hernia.
In a study of 65 adults who had a CT performed before CST, visceral fat volume was a significant predictor of reherniation (P = .025, odds ratio 1.65), reported Harm Winters of the department of plastic and reconstructive surgery at Radboud University Medical Center, Nijmegen, the Netherlands, and coauthors.
Patients were 18-75 years of age, and had complex ventral hernia repair via CST between 2000 and 2013. Patients were excluded if the CT scan was performed earlier than 6 months before hernia repair, or if the scan did not cover the full abdomen.
Visceral fat volume, subcutaneous fat volume, loss of domain, rectus thickness and width, abdominal volume, hernia sac volume, total fat volume, sagittal distance, and waist circumference were measured. Mesh reinforcement during surgery was used in 45 patients (69.2%), the authors noted.
Hernia sac volume and subcutaneous fat volume per 1,000 cm3 were significant predictors of surgical site infection (P = .020, OR 2.10 and P = .034, OR 0.26, respectively).
“These findings suggest that CT measurements are a valuable tool for preoperative risk assessment in patients undergoing complex ventral hernia repair using the CST,” the researchers wrote. Future trials should “further identify the role of these CT scan-derived body morphometrics for patient-tailored risk assessment,” they concluded.
No conflicts of interest were reported.
SOURCE: Winters H et al. Hernia. 2019 Mar 7. doi: 10.1007/s10029-019-01899-8.
Information obtained from computed tomography (CT) scans may help predict reherniation and surgical site infection (SSI) in patients who had complex ventral hernia repair with the component separation technique (CST), according to findings published in Hernia.
In a study of 65 adults who had a CT performed before CST, visceral fat volume was a significant predictor of reherniation (P = .025, odds ratio 1.65), reported Harm Winters of the department of plastic and reconstructive surgery at Radboud University Medical Center, Nijmegen, the Netherlands, and coauthors.
Patients were 18-75 years of age, and had complex ventral hernia repair via CST between 2000 and 2013. Patients were excluded if the CT scan was performed earlier than 6 months before hernia repair, or if the scan did not cover the full abdomen.
Visceral fat volume, subcutaneous fat volume, loss of domain, rectus thickness and width, abdominal volume, hernia sac volume, total fat volume, sagittal distance, and waist circumference were measured. Mesh reinforcement during surgery was used in 45 patients (69.2%), the authors noted.
Hernia sac volume and subcutaneous fat volume per 1,000 cm3 were significant predictors of surgical site infection (P = .020, OR 2.10 and P = .034, OR 0.26, respectively).
“These findings suggest that CT measurements are a valuable tool for preoperative risk assessment in patients undergoing complex ventral hernia repair using the CST,” the researchers wrote. Future trials should “further identify the role of these CT scan-derived body morphometrics for patient-tailored risk assessment,” they concluded.
No conflicts of interest were reported.
SOURCE: Winters H et al. Hernia. 2019 Mar 7. doi: 10.1007/s10029-019-01899-8.
FROM HERNIA
Evidence weak for robotic inguinal hernia surgery
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM MISS
Pregnancy after ventral hernia repair increased the risk for recurrence
concluded the authors of a systematic review of the literature on hernia and pregnancy.
Erling Omoa, MD, of Bispebjerg Hospital and the University of Copenhagen, and his colleagues surveyed 5,189 articles and chose four cohort studies, four case-control studies, and one case-series study that met their criteria of quality, comparability, and outcomes data. Only randomized, controlled trials, analytical observational studies, and large case series were included. The focus was primary ventral (umbilical and epigastric) and incisional hernia surgery before, during, and after pregnancy.
“The prevalence of clinically relevant primary ventral hernias is very low during pregnancy,” the investigators wrote, but there is a lack on consensus concerning the management of hernia repair in women of childbearing age. “The objective of this systematic review was to examine the risk of recurrence following prepregnancy ventral hernia repair, and secondly, to evaluate the prevalence of ventral hernia during pregnancy and the risk of surgical repair before and after childbirth,” they wrote.
The reviewers evaluated pregnancy following ventral hernia repair as a potential risk factor for hernia recurrence. One study found that subsequent pregnancy was associated with a 1.6-fold increased risk of recurrence. Another found that pregnancy was independently associated with a 73% raised risk of recurrence. The risk of recurrence was no different between mesh and suture repair.
The review found the prevalence of primary ventral and inguinal repair during pregnancy to be low. A single-center cohort study of 20,714 pregnant women of which 17 (0.08%) had umbilical hernias and none of these required repair before delivery. A case series of 126 women who underwent this surgery during pregnancy indicated that this procedure was associated with minimal 30-day morbidity and no deaths. No data was available on fetal morbidity or recurrence in this case series.
Case-control studies reporting on umbilical repair concomitant with elective C-section found that, although adding hernia repair to the procedure increased operative time in some studies, there was no additional complication risk.
Overall, the investigators found several areas in which evidence remains weak, such as the long-term risks for recurrence following pregnancy and long-term outcomes of mesh versus suture repairs. They recommended that patients be counseled on the risk of recurrence linked to subsequent pregnancies and that, if possible, ventral hernia repair should be postponed until after a last planned pregnancy. Watchful waiting until after a delivery was deemed safe in many cases.
The investigators reported no conflicts.
SOURCE: Oma E et al. Am J Surg. 2019 Jan;217:163-8.
concluded the authors of a systematic review of the literature on hernia and pregnancy.
Erling Omoa, MD, of Bispebjerg Hospital and the University of Copenhagen, and his colleagues surveyed 5,189 articles and chose four cohort studies, four case-control studies, and one case-series study that met their criteria of quality, comparability, and outcomes data. Only randomized, controlled trials, analytical observational studies, and large case series were included. The focus was primary ventral (umbilical and epigastric) and incisional hernia surgery before, during, and after pregnancy.
“The prevalence of clinically relevant primary ventral hernias is very low during pregnancy,” the investigators wrote, but there is a lack on consensus concerning the management of hernia repair in women of childbearing age. “The objective of this systematic review was to examine the risk of recurrence following prepregnancy ventral hernia repair, and secondly, to evaluate the prevalence of ventral hernia during pregnancy and the risk of surgical repair before and after childbirth,” they wrote.
The reviewers evaluated pregnancy following ventral hernia repair as a potential risk factor for hernia recurrence. One study found that subsequent pregnancy was associated with a 1.6-fold increased risk of recurrence. Another found that pregnancy was independently associated with a 73% raised risk of recurrence. The risk of recurrence was no different between mesh and suture repair.
The review found the prevalence of primary ventral and inguinal repair during pregnancy to be low. A single-center cohort study of 20,714 pregnant women of which 17 (0.08%) had umbilical hernias and none of these required repair before delivery. A case series of 126 women who underwent this surgery during pregnancy indicated that this procedure was associated with minimal 30-day morbidity and no deaths. No data was available on fetal morbidity or recurrence in this case series.
Case-control studies reporting on umbilical repair concomitant with elective C-section found that, although adding hernia repair to the procedure increased operative time in some studies, there was no additional complication risk.
Overall, the investigators found several areas in which evidence remains weak, such as the long-term risks for recurrence following pregnancy and long-term outcomes of mesh versus suture repairs. They recommended that patients be counseled on the risk of recurrence linked to subsequent pregnancies and that, if possible, ventral hernia repair should be postponed until after a last planned pregnancy. Watchful waiting until after a delivery was deemed safe in many cases.
The investigators reported no conflicts.
SOURCE: Oma E et al. Am J Surg. 2019 Jan;217:163-8.
concluded the authors of a systematic review of the literature on hernia and pregnancy.
Erling Omoa, MD, of Bispebjerg Hospital and the University of Copenhagen, and his colleagues surveyed 5,189 articles and chose four cohort studies, four case-control studies, and one case-series study that met their criteria of quality, comparability, and outcomes data. Only randomized, controlled trials, analytical observational studies, and large case series were included. The focus was primary ventral (umbilical and epigastric) and incisional hernia surgery before, during, and after pregnancy.
“The prevalence of clinically relevant primary ventral hernias is very low during pregnancy,” the investigators wrote, but there is a lack on consensus concerning the management of hernia repair in women of childbearing age. “The objective of this systematic review was to examine the risk of recurrence following prepregnancy ventral hernia repair, and secondly, to evaluate the prevalence of ventral hernia during pregnancy and the risk of surgical repair before and after childbirth,” they wrote.
The reviewers evaluated pregnancy following ventral hernia repair as a potential risk factor for hernia recurrence. One study found that subsequent pregnancy was associated with a 1.6-fold increased risk of recurrence. Another found that pregnancy was independently associated with a 73% raised risk of recurrence. The risk of recurrence was no different between mesh and suture repair.
The review found the prevalence of primary ventral and inguinal repair during pregnancy to be low. A single-center cohort study of 20,714 pregnant women of which 17 (0.08%) had umbilical hernias and none of these required repair before delivery. A case series of 126 women who underwent this surgery during pregnancy indicated that this procedure was associated with minimal 30-day morbidity and no deaths. No data was available on fetal morbidity or recurrence in this case series.
Case-control studies reporting on umbilical repair concomitant with elective C-section found that, although adding hernia repair to the procedure increased operative time in some studies, there was no additional complication risk.
Overall, the investigators found several areas in which evidence remains weak, such as the long-term risks for recurrence following pregnancy and long-term outcomes of mesh versus suture repairs. They recommended that patients be counseled on the risk of recurrence linked to subsequent pregnancies and that, if possible, ventral hernia repair should be postponed until after a last planned pregnancy. Watchful waiting until after a delivery was deemed safe in many cases.
The investigators reported no conflicts.
SOURCE: Oma E et al. Am J Surg. 2019 Jan;217:163-8.
FROM THE AMERICAN JOURNAL OF SURGERY
