- Email: [email protected]
Safety First, Total Cholecystectomy Second
Vol. 223, No. 3, September 2016
The steadily increasing demands of an aging population and dwindling surgeon-to-population ratio are likely to restrict access to surgical care.3,4 These demographic shifts were defined in the 2014 Institute of Medicine report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,5 and a recent report from the Association of American Medical Colleges titled, 2016 Update: The Complexities of Physician Supply and Demand: Projections from 2014 to 2015.3 In virtually all modeled scenarios, the supply of surgical specialists is projected to decline, with an estimated shortfall of 25,200 to 33,200 surgeons by 2025, at the same time that >20% of America’s population will be older than 65 years of age.3,4 The mounting pressure on decreasing numbers of surgeons to deliver quality care under these increasingly strained circumstances may exacerbate provider burnout. Recent media attention has scrutinized broad-ranging factors contributing to physician burnout, including increasing bureaucratization and overwhelming administrative responsibilities.6 In addition, these demands do not go unnoticed by our trainees. Fewer medical students are choosing careers in surgical subspecialties, often citing prolonged working hours and the perception of a worse lifestyle as main factors preventing recruitment.1,2 The dilemma of surgeon burnout defies easy remedy, in part because of the complicated multifactorial causes, but also, importantly, because the problem is under-reported. Physicians most likely to be burned out might be less likely to respond to research surveys.7 Dimou and colleagues2 reveal a striking dissonance between surgeons’ high self-reported rates of well-being and high objective measures of burnout. Significantly, surgeons reporting the lowest rates of well-being were least willing to pursue beneficial interventions. Perhaps it is time that we turned our attention to systems-level changes in addition to individual provider interventions, and examine the association between provider burnout and patient and caregiver outcomes. In summary, the constellation of escalating provider burnout rates, projected shortage of general surgeons, and declining rates of students pursuing surgical careers might lead to a perfect storm that threatens access to surgical care. Until we recognize, research, and confront the larger systems issues related to the phenomenon of provider burnout, self-directed interventions aimed at promoting surgeon well-being might fail to produce durable improvement. With this in mind, we recommend that additional investigations explore the causes and sequelae of burnout, including unintentional impacts on patient and caregiver outcomes. Such research can inform high-quality interventions for burnout prevention and
Letters
543
treatment. We commend the authors for their methodical and thorough contribution to this increasingly valuable body of work. REFERENCES 1. Elmore LC, Jeffe DB, Jin L, et al. National survey of burnout among US general surgery residents. J Am Coll Surg 2016. http://dx.doi.org/10.1016/j.jamcollsurg.2016.05.014 [Epub ahead of print]. 2. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: a systematic review. J Am Coll Surg 2016;222:1230e1239. 3. Association of American Medical Colleges. 2016 Update: The complexities of physician supply and demand: projections from 2014 to 2015. Available at: https://www.aamc.org/data/ workforce/reports/439206/physicianshortageandprojections.html. Published April 5, 2016. Accessed on April 22, 2016. 4. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States: population estimates and projections. Available at: http://www.census.gov/prod/2014pubs/ p25-1140.pdf. Accessed on April 22, 2016. 5. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academies Press; 2014.. 6. Ubel P. The joy has been sucked out of medicine. Here’s why. Available at: http://www.kevinmd.com/blog/2015/11/the-joyhas-been-sucked-out-of-medicine-heres-why.html. Accessed June 4, 2016. 7. Keeton K, Feener DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol 2007;109:949e955.
Disclosure Information: Nothing to disclose. Support: Dr Perumalswami is supported by the Robert Wood Johnson Foundation and the US Department of Veterans Affairs.
Safety First, Total Cholecystectomy Second Michael J Pucci, MD, FACS Philadelphia, PA L Michael Brunt, St Louis, MO Daniel J Deziel, Chicago, IL
MD, FACS
MD, FACS
We read with interest the paper titled, “A step-by-step guide to laparoscopic subtotal fenestrating cholecystectomy: a damage control approach to the difficult gallbladder,” by Dr Dissanaike.1 We applaud the author for presenting her experience managing the difficult
544
Letters
gallbladder by performing a laparoscopic subtotal cholecystectomy, specifically, the fenestrating subtype. As we have previously stressed, it is important to accurately define this operation to allow the surgeon a safe and effective “bail-out” when the Critical View of Safety is not achievable after a fair effort.2 Whether the optimal subtotal cholecystectomy is performed as either a reconstituting or fenestrating subtype remains to be determined, although it is our opinion that a fenestrating subtype may serve as the best definitive option for the difficult gallbladder.2 However, as the author nicely demonstrated, safely performing this procedure is not the difficulty in these cases. Instead, the challenge in the “difficult gallbladder” lies in the decision-making and knowledge of the surgeon to know when danger lies ahead. In fact, it is our opinion that surgeons should err on the side of safety when it is unclear whether the Critical View of Safety is achievable.2-4 Therefore, we do not think this procedure is merely a “damage control” option for the difficult gallbladder; instead, we view it as a safe, effective, and reasonable method of completing the desired course of action in cholecystectomy. Additionally, it is our experience that mandatory postprocedural endoscopic retrograde cholangiography with endoscopic sphincterotomy is not, in fact, necessary; instead, it is the exception. When bile fistula occurs, it appears to be largely selflimiting. We believe this is an important distinction because if surgeons believe a “second” procedure is necessary when performing a subtotal fenestrating cholecystectomy, they may be tempted to push on in a dangerous scenario in order to avoid this second procedure. This persistence in the face of biliary fusion and contraction may lead to bile duct injury. In order to avoid this situation, prophylactic drainage of Morison’s pouch to control a bile fistula, if one develops, may be the best option. Additionally, instead of placing a drain within the opened lumen of
J Am Coll Surg
the remnant gallbladder, we recommend an attempt at suture closure of the internal orifice of the cystic duct when bilious leakage is visible. However, many times this cystic duct will be “obliterated” by inflammation and is not patent. In this circumstance, a simple drain in Morison’s pouch may be all that is necessary. That said, we would like to commend the author for clearly demonstrating a simple method of “getting out of dodge” when the risk of bile duct injury is high. We hope this helps support the widespread adoption of the Culture of Safety in Cholecystectomy and use of the appropriate nomenclature to define a safe and effective procedure when the Critical View of Safety cannot be obtained.3,5,6 Remember, safety first, total cholecystectomy second.
REFERENCES 1. Dissanaike S. A step-by-step guide to laparoscopic subtotal fenestrating cholecystectomy: a damage control approach to the difficult gallbladder. J Am Coll Surg 2016;223:e15ee18. 2. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. Subtotal cholecystectomy - “fenestrating” vs. “reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 2016;222: 89e96. 3. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010; 211:132e138. 4. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101e125. 5. Society of American Gastrointestinal and Endoscopic Surgeons. The SAGES Safe Cholecystectomy Program. Available at: http://www.sages.org/safe-cholecystectomy-program/. Accessed June 11, 2016. 6. Strasberg SM. A teaching program for the “culture of safety in cholecystectomy” and avoidance of bile duct injury. J Am Coll Surg 2013;217:751.
Disclosure Information: Nothing to disclose.
The steadily increasing demands of an aging population and dwindling surgeon-to-population ratio are likely to restrict access to surgical care.3,4 These demographic shifts were defined in the 2014 Institute of Medicine report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,5 and a recent report from the Association of American Medical Colleges titled, 2016 Update: The Complexities of Physician Supply and Demand: Projections from 2014 to 2015.3 In virtually all modeled scenarios, the supply of surgical specialists is projected to decline, with an estimated shortfall of 25,200 to 33,200 surgeons by 2025, at the same time that >20% of America’s population will be older than 65 years of age.3,4 The mounting pressure on decreasing numbers of surgeons to deliver quality care under these increasingly strained circumstances may exacerbate provider burnout. Recent media attention has scrutinized broad-ranging factors contributing to physician burnout, including increasing bureaucratization and overwhelming administrative responsibilities.6 In addition, these demands do not go unnoticed by our trainees. Fewer medical students are choosing careers in surgical subspecialties, often citing prolonged working hours and the perception of a worse lifestyle as main factors preventing recruitment.1,2 The dilemma of surgeon burnout defies easy remedy, in part because of the complicated multifactorial causes, but also, importantly, because the problem is under-reported. Physicians most likely to be burned out might be less likely to respond to research surveys.7 Dimou and colleagues2 reveal a striking dissonance between surgeons’ high self-reported rates of well-being and high objective measures of burnout. Significantly, surgeons reporting the lowest rates of well-being were least willing to pursue beneficial interventions. Perhaps it is time that we turned our attention to systems-level changes in addition to individual provider interventions, and examine the association between provider burnout and patient and caregiver outcomes. In summary, the constellation of escalating provider burnout rates, projected shortage of general surgeons, and declining rates of students pursuing surgical careers might lead to a perfect storm that threatens access to surgical care. Until we recognize, research, and confront the larger systems issues related to the phenomenon of provider burnout, self-directed interventions aimed at promoting surgeon well-being might fail to produce durable improvement. With this in mind, we recommend that additional investigations explore the causes and sequelae of burnout, including unintentional impacts on patient and caregiver outcomes. Such research can inform high-quality interventions for burnout prevention and
Letters
543
treatment. We commend the authors for their methodical and thorough contribution to this increasingly valuable body of work. REFERENCES 1. Elmore LC, Jeffe DB, Jin L, et al. National survey of burnout among US general surgery residents. J Am Coll Surg 2016. http://dx.doi.org/10.1016/j.jamcollsurg.2016.05.014 [Epub ahead of print]. 2. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: a systematic review. J Am Coll Surg 2016;222:1230e1239. 3. Association of American Medical Colleges. 2016 Update: The complexities of physician supply and demand: projections from 2014 to 2015. Available at: https://www.aamc.org/data/ workforce/reports/439206/physicianshortageandprojections.html. Published April 5, 2016. Accessed on April 22, 2016. 4. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States: population estimates and projections. Available at: http://www.census.gov/prod/2014pubs/ p25-1140.pdf. Accessed on April 22, 2016. 5. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academies Press; 2014.. 6. Ubel P. The joy has been sucked out of medicine. Here’s why. Available at: http://www.kevinmd.com/blog/2015/11/the-joyhas-been-sucked-out-of-medicine-heres-why.html. Accessed June 4, 2016. 7. Keeton K, Feener DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol 2007;109:949e955.
Disclosure Information: Nothing to disclose. Support: Dr Perumalswami is supported by the Robert Wood Johnson Foundation and the US Department of Veterans Affairs.
Safety First, Total Cholecystectomy Second Michael J Pucci, MD, FACS Philadelphia, PA L Michael Brunt, St Louis, MO Daniel J Deziel, Chicago, IL
MD, FACS
MD, FACS
We read with interest the paper titled, “A step-by-step guide to laparoscopic subtotal fenestrating cholecystectomy: a damage control approach to the difficult gallbladder,” by Dr Dissanaike.1 We applaud the author for presenting her experience managing the difficult
544
Letters
gallbladder by performing a laparoscopic subtotal cholecystectomy, specifically, the fenestrating subtype. As we have previously stressed, it is important to accurately define this operation to allow the surgeon a safe and effective “bail-out” when the Critical View of Safety is not achievable after a fair effort.2 Whether the optimal subtotal cholecystectomy is performed as either a reconstituting or fenestrating subtype remains to be determined, although it is our opinion that a fenestrating subtype may serve as the best definitive option for the difficult gallbladder.2 However, as the author nicely demonstrated, safely performing this procedure is not the difficulty in these cases. Instead, the challenge in the “difficult gallbladder” lies in the decision-making and knowledge of the surgeon to know when danger lies ahead. In fact, it is our opinion that surgeons should err on the side of safety when it is unclear whether the Critical View of Safety is achievable.2-4 Therefore, we do not think this procedure is merely a “damage control” option for the difficult gallbladder; instead, we view it as a safe, effective, and reasonable method of completing the desired course of action in cholecystectomy. Additionally, it is our experience that mandatory postprocedural endoscopic retrograde cholangiography with endoscopic sphincterotomy is not, in fact, necessary; instead, it is the exception. When bile fistula occurs, it appears to be largely selflimiting. We believe this is an important distinction because if surgeons believe a “second” procedure is necessary when performing a subtotal fenestrating cholecystectomy, they may be tempted to push on in a dangerous scenario in order to avoid this second procedure. This persistence in the face of biliary fusion and contraction may lead to bile duct injury. In order to avoid this situation, prophylactic drainage of Morison’s pouch to control a bile fistula, if one develops, may be the best option. Additionally, instead of placing a drain within the opened lumen of
J Am Coll Surg
the remnant gallbladder, we recommend an attempt at suture closure of the internal orifice of the cystic duct when bilious leakage is visible. However, many times this cystic duct will be “obliterated” by inflammation and is not patent. In this circumstance, a simple drain in Morison’s pouch may be all that is necessary. That said, we would like to commend the author for clearly demonstrating a simple method of “getting out of dodge” when the risk of bile duct injury is high. We hope this helps support the widespread adoption of the Culture of Safety in Cholecystectomy and use of the appropriate nomenclature to define a safe and effective procedure when the Critical View of Safety cannot be obtained.3,5,6 Remember, safety first, total cholecystectomy second.
REFERENCES 1. Dissanaike S. A step-by-step guide to laparoscopic subtotal fenestrating cholecystectomy: a damage control approach to the difficult gallbladder. J Am Coll Surg 2016;223:e15ee18. 2. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. Subtotal cholecystectomy - “fenestrating” vs. “reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 2016;222: 89e96. 3. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010; 211:132e138. 4. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101e125. 5. Society of American Gastrointestinal and Endoscopic Surgeons. The SAGES Safe Cholecystectomy Program. Available at: http://www.sages.org/safe-cholecystectomy-program/. Accessed June 11, 2016. 6. Strasberg SM. A teaching program for the “culture of safety in cholecystectomy” and avoidance of bile duct injury. J Am Coll Surg 2013;217:751.
Disclosure Information: Nothing to disclose.