BBI Contributing Editor

NEW ORLEANS –With an attendance in excess of 12,000, more than half of whom were surgeons, the annual meeting of the American College of Surgeons (ACS; Chicago) here in October offered a peek into the future on many fronts, including surgical resident training and in-practice education, minimally invasive breast surgery, bariatric surgery, surgical sealants and the operating room of the future and in the battlefield – all of which were so forward-thinking, one might have thought he or she was at a sci-fi conference.

Northwestern University's Center for Advanced Surgical Education (Evanston, Illinois), under the guidance of the board of surgery, has developed the first web-based interactive educational module for surgical residents. The objective is to provide a uniform standard of education to all 275 surgery resident programs across the nation. The first pilot module, which was being shown and tested by residents at this show, was on breast disease management. The module teaches every aspect of breast care beginning with anatomy and physiology through diagnosis, cancer therapy and patient follow-up. Throughout the training program are a series of required tests that determine whether the resident is prepared to continue the training or needs more help. At any given point, more detailed information is available by clicking on a keyword which prompts to another web site dedicated to that specific topic or even forwards the student to a video didactic showing in greater detail the point of the discussion where more knowledge is needed. The residents are allowed to take self-administered quizzes throughout the training module before they attempt the true test that will determine whether they are either allowed to pass on to the next chapter or are required to repeat the section until better expertise is demonstrated. These online tests are monitored so that the proctor knows at any time how well the resident is progressing in a certain area. This program, once finalized, could become the standard of education for residents in every field of surgery and at every resident program.

Following resident training, there is surgeon training once in practice. In a presentation titled "The Operating Room of the Future," Adrian Park, MD, chief of general surgery at the University of Maryland School of Medicine (Baltimore), demonstrated what the OR of the future might look like. Using advanced imaging modalities, he suggested that surgeons could pre-operatively "operate" on a hologram of the patient next in line for surgery in order to practice the operation prior to performing the real surgery. By doing so, any unusual anatomy could be navigated and strategic determinations could be made prior to opening the patient and finding "surprises." Some of this same holographic surgery also could be applied to battlefield surgery, where the surgeon could be in a safe place operating on a remote wounded soldier using robots. Both the OR of the future and battlefield surgery tactics would involve informatics, which is the integration of data, images, search and connectivity, and is predicted to be in use within the next 10 years.

In what is now well known, but at the time was breaking news presented at the ACS, Henry Buchwald, MD, professor in the department of surgery at the University of Minnesota (Minneapolis), presented the results of a meta-analysis of 136 studies involving 22,094 patients who underwent bariatric surgery. It showed that bariatric surgery was a therapeutically and cost-effective solution to the four most common co-morbidities of obesity: hypertension, diabetes, sleep apnea and hyperlipidemia. Overall mortality rates were low (0.68%), and a large majority (89%) of morbidly obese patients had total resolution or marked improvement of their co-morbid conditions after bariatric surgery. These surgical procedures may well be a life-saving operation for morbidly obese patients.

Minimally invasive breast surgery continues to take advantage of advancements in new technologies. Suzanne Klimberg, MD, of the University of Arkansas for Medical Sciences (Little Rock, Arkansas), presented a novel approach that utilizes radio frequency (RF) ablation immediately post-lumpectomy to improve recurrence rates and cosmesis. Before unveiling her new procedure, she first updated the audience with all currently available excisional biopsy tools, including the Vacora from C.R. Bard (Murray Hill. New Jersey); EnCor from Senorx (Aliso Viejo, California); Cassi from Sanarus (Pleasanton, California); EnCapsule from Rubicor (Redwood City, California); Atec, the magnetic resonance image-guided system from Suros (Indianapolis); and the new improved Mammotome from the Ethicon (Somerville, New Jersey) division of Johnson & Johnson (New Brunswick, New Jersey). All of these devices are designed to improve re-excision rates that can include up to 40% of all biopsies, and maintain a good cosmetic effect by utilizing imaging with minimally invasive technologies for cutting breast tissue.

About 20% of all biopsies will result in a surgical procedure to remove the tumor, which is when Klimberg is using a revolutionary technique on select patients who could benefit from RF ablation of the tumor bed following lumpectomy. Using the device manufactured by RITA Medical Systems (Mountain View, California), Klimberg performed a lumpectomy on 25 patients followed by ablation of their tumor beds using RF energy. Seven of these patients were found to have had positive margins, but because their tumor bed had been ablated they did not have to return for a re-excision. At two years out, none of these patients have had a recurrence.The importance of this study is that if it can be proven that RF ablation offers the same protection against cancer recurrence as radiation therapy, then all patients could have a single procedure that includes RF ablation and not have to return for a second surgery. An additional benefit is that when there is a poor cosmetic outcome, it is usually due to the re-excision, so by eliminating a second surgery the patient has a much better cosmesis. There also would be significant cost savings, since not only is radiation therapy expensive, but an additional specialist – the radiation oncologist – is required. The concept of being able to ablate instead of radiate holds great appeal for both patients and breast surgeons.

Used more and more prevalently – but often only for specific applications – are surgical tissue adhesives and sealants (see Table 1). William Spotnitz, MD, of the University of Florida Health Science Center (Gainesville, Florida), moderated a postgraduate course on "Advances in Tissue Adhesives" which courted an audience of about 200 surgeons. He first described the "ideal adhesive" as being one that is safe, effective, has good usability, is affordable and has FDA approval. Spotnitz said that surgical practice is changing, as are the needs for more practical solutions for some surgical issues that adhesives can provide. He cited specific examples such as using a tissue adhesive for packing following nasal surgery as opposed to the old-fashioned packing that was time -consuming and patient-unfriendly, closing skin incisions (especially pediatric) with glue instead of using sutures, gluing the intima of a dissecting aortic aneurysm before placing the graft – all of these procedures, and others, benefit the patient and have changed the way surgery is performed. Patients have greater satisfaction, fewer blood transfusions are required, morbidity and mortality are improved, operating room time is reduced and patients don't have to return to have sutures removed. All of these contribute to reduced costs as well as improved patient satisfaction.

The first family of adhesives is fibrin sealants, which are biodegradable, hemostatic and, in the future, given FDA approval, also could be used as a drug-delivery agent. Since they are derived from human blood components, there is a slight risk of HIV and other viral transmissions, but because there have been so many precautions taken with blood-derived products, there have been no reported cases of HIV transmission from any of the 4 million uses in the U.S. Although it has been used in almost all areas of the body, it is FDA-approved for use in cardiac, splenic, liver and colon surgery. It can be used as an anti-adhesive as well if the surgeon delays the closing of two tissues that have been coated with the product.

The second family of adhesives is cyanoacryolates. Dermabond, distributed by Ethicon, and Indermil from United States Surgical (Norwalk, Connecticut), are akin to Crazy Glue. These are 100% synthetic and nonabsorbable, so long-term safety has not yet been determined, leaving a potential risk for foreign body reaction, allergic response, and carcinogenicity if used internally. Until that is understood, its use is limited to low-tension skin incisions and AVM embolisms in the brain. The latter is acceptable because the embolism will be removed surgically once the clot has formed and stopped the bleeding in the brain. These products have limited hemostatic properties but work exceptionally well when used as directed. In fact, Dean Toriumi, MD, of the University of Illinois-Chicago, showed in a study that on average, sutures required about four minutes of operating room time per patient vs. an average of 55 seconds per patient using superficial "glue" closure. In addition to saving precious OR time, the patient does not have to return to the doctor's office to have the sutures removed. This is an exceptionally well-received benefit for parents of children and for patients who live in remote areas.

The third family of sealants involves collagen and thrombin products such as Floseal, which are biodegradable and used for all surgical procedures to attain hemostasis, though they do not perform as a glue. Many of these are derived from bovine sources, so a concern exists about their safety.

The fourth family of tissue adhesives includes a product made from PEG polymers, CoSeal surgical sealant, manufactured by Baxter Healthcare (Fremont, California). CoSeal is a surgical sealant that helps to stop leaks in blood vessels. It is totally synthetic, resorbable and best used on a dry surface. It most often is used to stop vascular bleeding, especially around suture lines.

The fifth and final product group is albumin crosslinked gluteraldehyde, represented by the BioGlue product from CryoLife (Kennesaw, Georgia). It also is bovine-derived and may be neurotoxic, but it has been proven to be a successful adjunct for acute aortic dissection when placing the "glue" inside the false lumen prior to suturing in the graft. Studies have shown no increased complications, a decrease in OR time, and decreased costs when using Bioglue for acute aortic dissection.

As was obvious from the breadth and depth of product offerings on the sprawling ACS exhibit floor in the Ernest N. Morial Convention Center, the fields of surgery are taking advantage of many new advancements on several fronts.