Minimizing Risk from a Surgeon’s Perspective

1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future Minimizing Risk from a Surgeon’s Perspective Gary Gibbons, MD President and CEO Quincy Medical Center Executive Director, Foot Care Specialists and Chief of Vascular Surgery of Boston Medical Center Boston University School of Medicine May 18, 2006 9:00-9:30am

2. If you developed an asymptomatic 6cm abdominal aortic aneurysm, what would you do? QUESTION: • Nothing…just follow • Traditional open repair • Endovascular repair 0/0

3. Following an open AAA repair in a diabetic patient, what glucose range do you attempt to maintain post-operatively? QUESTION: • 80 – 100 • 100 – 140 • 140 – 200 • > 200 0/0

4. Case MJ • 65 year old moderately obese, diabetic male, former smoker • 6 cm asymptomatic AAA • Poorly controlled DM with Hgb A1c > 7 • Additional risk factors hypertension, albuminuria, mild renal insufficiency, hyperlipidemia

5. Management Options for this patient with an asymptomatic 6 cm Abdominal Aortic Aneurysm • Observation • Risk of rupture 10-15%/ year • Open Repair – traditional • Endovascular Repair

6. Open Surgical Approach for AAA • Historical gold standard • Effective and durable • Acceptable risk of major morbidity or mortality 5-10% • Recovery can take several months • Less follow up • Effort to find less invasive approach to repair aneurysm with reduced mortality and improved quality of life

7. OPEN EVAR

8. Endovascular Repair • Anesthesia: general, regional or local with sedation • Advantages • Less morbid • Quicker return to function and well being • Less frequency of impotence and retrograde ejaculation (open risk 60-70%) • Disadvantages • Lifelong follow up required since durability of grafts unknown • Secondary interventions

9. Secondary Intervention • Incidence is 10-18% using a variety of different endografts • AneuRx EVAR • Freedom from secondary intervention at 1 and 3 years • open 97%, 93% • endovascular repair 94%, 55% • Exclusion of the early prototype from the analysis showed endovascular freedom from secondary intervention to be 100% and 90%

10. Modern Day Surgery • Tailor the operation to meet each individual patient’s needs and expectations • Consider comorbid conditions and patient well being

11. Data Gathering Phase • Detailed history and physical • Consider all of the details of the procedures under consideration • Previous surgical history • Hostile abdomen • Prior illnesses, medications, allergies, family history

12. Data Gathering Phase • AAA as a marker for generalized atherosclerotic vascular disease • Diabetes and its effects • Patient’s perception of his illness • Patient’s understanding of his options • Are expectations realistic? • Potency can be a major issue • Return to work • Insurance issues • Compliance (especially for endovascular repair)

13. Data Gathering Phase • Basic laboratory tests • CXR • EKG • Spiral CTA with fine cuts and 3-D reconstruction optimal • Dye considerations • Prophylactic measures for nephropathy • Allergy • Hold Metformin • Renal protection

14. Decision Making Phase • Consider data in selecting the best procedure for that patient • Discussions with primary medical doctor • Cardiology clearance? • Perioperative Beta-blockers • Anesthesia input for risk stratification • Selection of anesthetic technique

15. Decision Making Phase • Optimization of glucose control in diabetics • Role hygiene plays in wound complications • Risk / benefit ratio • Outcomes • Communication with the patient about these risks • Informed consent and minimizing legal risk

16. Decision Making Phase • Risks • Transfusion • Impotency • Paraplegia • Multidisciplinary effort

17. Perioperative Management • Preoperative essentials • Medical optimization of comorbidities • Positive attitude of patient • Consent for surgery and possible blood transfusion explained • Anesthesia consultation for perioperative pain management • Preoperative antibiotics and insulin • Shaving in holding area to reduce risk of infection

18. Perioperative Management • Intraoperative Management • Laterality determined and marked • Appropriate studies in the room • Ancillary equipment (i.e. C arm, Cell saver) • Obligatory blank Anesthesia time • Procedural preparedness • 3 strategies to achieve the goal of the case • Primary surgeon focused on the case • Assistant in communication with anesthesia • Shared decision making • Predicting the unpredictable

19. Perioperative Management • Predicting the unpredictable • Confront issues and complications immediately • Never be afraid to ask for advice or help • Remember: the patient comes first !!! • Egos left at the door

20. Perioperative Management • Intraoperative Management (continued) • Once incision closed, and dressing on, surgeon’s job not complete • Assess pulses, general appearance of patient and overall outcome • Re-review films • Note complications and address • Communication with patient, family, risk management, supervisors • Advice from colleague or friend • Anything that could have been done differently

21. Perioperative Management • Postoperative management • Surgeon or assistant should accompany anesthesia to the recovery room • Communicate with anesthesia or nurses about procedure and what to expect • Pain issues, fluid requirements, transfusion issues • Talk to family immediately • Diabetics – control BP, glucose • Tight control of blood sugar in perioperative period reduces wound infection rates and complications

22. Perioperative Management • Postoperative management • Surgeon or assistant should accompany anesthesia to the recovery room • Communicate with anesthesia or nurses about procedure and what to expect • Pain issues, fluid requirements, transfusion issues • Talk to family immediately

23. Perioperative Management • Postoperative management • Diabetics – control BP, glucose • Tight control of blood sugar in perioperative period reduces wound infection rates and complications • DVT prophylaxis • Perioperative antibiotics, beta-blockers and ASA • Labs, X-rays • Mobilization and pain control • Discharge expectations and follow up

24. Summary • Every operation must be well scripted & choreographed • Even simple procedures require good communication with patient • Minimization of risk requires team communication and dismissal of silos • Patient care is paramount • Even in the best of circumstances complications happen • Complexity of surgery and illness of patient

25. Summary (continued) • Team preparation, communication, professionalism, competence and efficiency allow best outcome for the patient • Treat the patient like one of your family