SAGES

Reimagining surgical care for a healthier world

SAGES ADOPT Program

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Acquisition of Data for Outcomes and Procedure Transfer

Brian J. DunkinBy Brian Dunkin, MD, SAGES Past President

When was the last time you learned a completely new procedure and brought it to the operating room for the first time? How did you do it? Read a book? Watched a video? Attended a course? Worked with a colleague? Chances are, it was a combination of all of these things. And, you had to do it on your own.

Isn’t it amazing that in these modern times of rapid change in surgery there is no real infrastructure to help practicing surgeons learn new techniques and safely adopt them into practice? SAGES is working to change that.

One of the SAGES programs that is changing how practicing surgeons learn new operations is called ADOPT (Acquisition of Data for Outcomes and Procedure Transfer). This innovative program transforms the usual hands-on post-graduate course conducted during the SAGES annual meetings into a gateway to a one-year longitudinal curriculum that is improving successful procedural adoption.

ADOPT is the brainchild of the Continuing Education Committee, currently led by Drs. John Paige, Elisabeth McLemore, Vanessa Palter, and Jonathan Dort as well as myself. It was first introduced at the 2015 annual meeting with a focus on abdominal wall reconstruction and a second round of training was again offered in 2016.

The ADOPT pathway begins by ensuring that the expert faculty who are going to be instructors for the program are also excellent teachers. Each ADOPT expert must attend a special train-the-trainers (TT) course to prepare them to be good surgical coaches.

Next, mentees who enroll in the program must complete a pre-course survey to understand their practice better and what they hope to gain from the course (See Figure Below). Then, during the annual meeting mentees participate in a hands-on training program with their expert mentors. During the training, mentees are asked about their specific goals and the course experience is modified to meet them. By the end of the day, the experts have come to understand each trainee’s needs and skills and assigned them a personal take-home message to work on before their first case.

As the year progresses, there are multiple touch points for mentors and mentees to connect in order to help the mentees navigate through the early part of their learning curve. These touch points include webinars, video review of actual procedures, and a face-to-face meeting at the American College of Surgeons annual meeting. The International Hernia Collaborative Facebook page was also used to foster immediate from an expert on-line community to provide input on challenges faced in adopting new procedures and managing difficult patients. In addition, mentees complete 3 and 6 month surveys about their performance of abdominal wall reconstruction. The whole program concludes with a presentation of results at the next SAGES annual meeting.

ADOPT is not only providing a better training curriculum, it is also creating a community where expert and less experienced surgeons can come together to foster successful procedural adoption. The results so far have been impressive. In December 2016 Jonathan Dort et al. published the results of the ADOPT program in Surgical Endoscopy (DOI 10.1007/s00464-016-5366-z published on-line December 2016).

To quote: “Over the 3 months following the course, ADOPT participants performed more ventral hernia mesh insertion procedures than standard training participants (median 13 vs. 0.5, p = 0.010) and considerably more total combined procedures (median 26 vs. 7, p = 0.054). Compared to standard training, learners who participated in ADOPT reported greater confidence in employing a components separation via an open approach (p = 0.051).”

Following on the success of the ADOPT program to teach practicing surgeons advanced techniques in abdominal wall reconstruction, the same methodology is being applied to teach laparoscopic colectomy at the SAGES 2017 Annual Meeting in Houston, Texas. Led by Drs. Jaime Sanchez and Peter Marcello, the ADOPT colectomy program will guide practicing surgeons to adopt laparoscopic right and left colectomy into their practice.
With programs like SAGES ADOPT, no longer are annual meeting post-graduate courses a single event that is unlikely to lead to successful procedural adoption. Now, these courses are the entryway into a 12 month longitudinal training program conducted by expert coaches. So stop relying on YouTube, out-of-date text books, and cryptic articles to learn a new procedure.

Sign-up for ADOPT and join a community of surgeons like yourself receiving expert guidance from mentors who have taken the time to learn how to be effective coaches.

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Message from The President

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Daniel J. Scott, MD

Daniel J. Scott, MD, FACS, President, SAGES

When assuming the SAGES presidency 11 months ago, I could not imagine what the year would entail and how fast the time would go by. Indeed, I now find myself drafting my annual meeting presidential address and this, my last message to the full SAGES membership. Thank you for the opportunity to lead and guide SAGES in the past year – this has been a fantastic honor and I am extremely proud of the great people we have in our organization.

We have indeed had a busy year with countless conference calls and meetings. Much to my delight, we have made significant progress in many areas and our organization remains quite strong. We have been fortunate enough to invest in several new initiatives over the past few years, over and above our annual budget. To balance that innovation and fiscal responsibility, the Executive Committee and Board agreed this year would be budget neutral. We have requested greater involvement from committee chairs in budget oversight, in addition to the standard staff, Finance & Executive Committee oversight. In addition, we asked our Development committee to embark upon an Alternative Funding Solutions initiative.

Over the past several years, the size, scope and number of SAGES educational initiatives has increased substantially. All of these are exciting and innovative projects, and all will advance innovation and patient care. We have been grateful for the generous support of our industry partners over the years, and we anticipate that they will continue to support SAGES educational initiatives, including our upcoming annual meeting. In addition, the SAGES Foundation continues to be a major supporter of many of our initiatives, especially in their early stages of development. However, as much as we appreciate the support of our industry partners and the Foundation, we cannot continue to rely solely on them to fund an ever-increasing list of activities. At the same time, SAGES cannot continue to move educational initiatives forward without funds to support them. To that end, SAGES has begun a focused initiative to explore, research, and obtain funding from alternative sources, including government agencies, such as NIH and AHRQ, and private foundations. This alternative funding solution initiative is multi-pronged, and includes identifying current funding opportunities for existing projects, while simultaneously developing forward-thinking plans and proposals to obtain grants for long-term educational initiatives, research, and programs. Success in this new arena will provide exciting new opportunities for SAGES, and enable us to take our organization to the next level in the advancement of education, innovation, and patient care.
Another major initiative we undertook this year was to launch a long overdue exploration of the fellowships affiliated with SAGES. The first step was to formally transition the former Resident Education Committee into the Resident and Fellowship Training (RAFT) Committee. By commissioning RAFT to take a lead role in fellowship curriculum development, SAGES is capitalizing on an opportunity to redefine MIS Fellowships at a time when surgical education is evolving at all levels. Working in partnership with the Fellowship Council, this initiative will ultimately revamp the curricula for GI surgery fellowships, standardize and enhance training by incorporating Entrustable Professional Activities (EPAs) as a competency metric, and align with the impending changes in General Surgery residency. As important, the process will better define and underscore the value of maintaining the MIS name in these fellowships, a move overwhelmingly supported by the SAGES Board at our Spring 2016 meeting.

I hosted an executive committee retreat last August, in an effort for us to spend time critically thinking about several aspects of our organization. We surveyed our board members, committee chairs, and numerous past presidents prior to this meeting to identify areas that needed to be addressed. This meeting was fruitful, and solidified our action plans to optimize our organizational infrastructure, including efforts to streamline our governance processes and enhance communication between committees. Arguably, as a result, we had one of our best fall board meetings, which fostered in-depth discussions about substantial and relevant issues. We also established plans to explore alternative funding pathways, opportunities to enhance science in our field, and increase our value to members and the public.

Our Curriculum Task Force has made tremendous strides towards the realization of our SAGES University Masters Program. When the program is fully launched next year, SAGES members will be able to choose clear pathways of coursework that progress from a Competency Curriculum to Proficiency to Mastery in eight areas of focus (Acute Care, Bariatric, Biliary, Colon, Flexible Endoscopy, Foregut, Hernia, and Robotics). The Masters Program will not only leverage the wealth of existing SAGES educational resources, but in keeping with the philosophy of our Society, we will capitalize on technological advancements to improve the process. We’re exploring a new software platform to house all SAGES educational offerings, and the program will take advantage of social media to drive further engagement and skills assessment. You can start your foray into the Masters Program at SAGES 2017 by taking one of our Masters Series Courses and by looking for the launch announcement of our eight Masters Program Facebook Collaborative Groups.

The FES team has been working closely with the American Board of Surgery to ensure SAGES and residency program directors are prepared for the ABS mandate and that all members of the 2018 graduating surgical residency class pass the FES exam prior to sitting for their surgical boards.

Many FES test centers are operational, and the majority of general surgery residents are within 50 miles of one. Testing is also available during the SAGES & ACS conferences.

A wealth of innovative educational and scientific updates await you at the SAGES 2017 annual meeting, March 22-25 in Houston.

New features unique to 2017 include:

  • “Your Sessions”, with lecture topics selected by you, SAGES membership
  • SAGES “Video Face-Off” featuring pre-recorded video sessions from experts showing different approaches to procedures
  • “Let’s Do Lunch” provides an open forum to discuss specific topics of interest with your peers
  • Keynote lectures by Brian Jacob, MD, Dave Kerpen and Jaap Bonjer, MD
  • SAGES Gala at the Space Center
  • And much more!
    Register now at sages2017.org

Without experimentation, it is impossible to innovate. SAGES has grown to 36 committees and task forces, each with a unique mandate and goals. Our committee chairs work tirelessly on a weekly, sometimes daily basis, in addition to their busy surgical practices. 618 members serve on one or more committees to further the work of the Society. SAGES Board of Governors and Executive Committee not only meet in person, but electronically and by conference call throughout the year to ensure the Society is reaching its goals, approving committee initiatives and continuing to lead in the world of surgery. To each of these leaders, and to the more than 6300 SAGES members across the globe, I am grateful. It has been an honor and pleasure to serve as your President.

Daniel J. Scott, MD, FACS, SAGES President

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New SAGES Video Library Search

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The SAGES Video Library has always been one of our website’s signature features. Since 2008, we have been recording videos from our annual meeting and since 2011 we have also allowed our members to donate their own videos to SAGES to help educate their colleagues.  All of our videos are hosted on YouTube as a service to the surgical community and we encourage our community to share our videos far and wide to further our mission of quality surgical education.

But by 2015, we realized that we had so many videos with similar topics that people were having a very hard time finding a specific video or finding a video that suited their needs.  So the SAGES Board of Governors tasked the Communications Committee to bring order from the chaos and overhaul the search and categorization systems for the SAGES Videos.

After a year of effort and watching a lot of videos, we are happy to report the new SAGES Video Library search is now available for all users of the SAGES web site at: https://www.sages.org/video-search/

You can now search and filter our videos using the following methods:

  • Keyword Search – Search the “normal” way by entering a keyword or words and the site will attempt to find all videos which match your request.
  • Filter by Pathway – Want to see just Hernia videos? No problem! Our search page allows you to filter the list of videos by topic and allows to browse our collection if you don’t quite know what you are looking for.
  • Filter by Source – You can also filter by the video source, so it is easier to watch a replay from a SAGES Annual Meeting or see that specific FUSE video you missed.
  • Filter by Type – Looking for a past President’s Address or a How-To video? We are currently working on adding additional filters by the type of video to help you find things even faster.

And we have barely scratched the surface of the improvements coming to the Video Library Search.  In the coming months, we will be adding timestamps for points of interest to all videos, classify them by difficulty level, add tons of tags and synonyms to the search algorithm and more. If you have any feedback or questions, please contact Jason C. Levine at the SAGES office at webmaster@sages.org.

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The Fundamental Use of Surgical Energy – FUSE

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By Dr. Daniel B. Jones, President-Elect, SAGES

The Fundamental Use of Surgical Energy(TM) initiative was conceived and initiated in 2010 by then SAGES president-elect Steven Schwaitzberg. He recognized that surgeons have a very rudimentary understanding of the physics behind the surgical energy devices they use every day in the operating room. As such, they were, and still are,  placing their patients at risk.  Every year there are approximately 400 OR fires and 40,000 thermal injuries, with many more that were likely go unreported.  We coined the project “FUSE.”

The Task Force, initially led by Daniel Jones, Liane Feldman, and Pascal Fuchshuber, recruited experts in surgical  energy and the associated risks across many disciplines:  anesthesia, gynecology, urology, bariatrics, colorectal surgery, general surgery, hepatobiliary surgery, flexible endoscopy and very importantly – nursing .  The mantra became “energy injuries are team failures.” One of the initial challenges was that there was no textbook to turn to.  So the Task Force authored the “SAGES Manual on the Fundamental Use of Surgical Energy (FUSE)” by Springer, 2013. This paperback has become the “go- to” reference in our field.

Predictably,  many surgeons were skeptical that FUSE was needed in the surgical community.  They cited that the FUSE program was costly and unnecessary.  It was common to hear, “Surgeons operate every day – of course we are experts,” or “We don’t need another burdensome course.”  So the first thing the Task Force did was identify 20 concepts that all surgeons would need to know to be safe in relation  to energy devices.  This mini-exam was administered to the SAGES Board of Governors.  Nearly 70% failed and did not know basic concepts. [i]   It was no longer OK to ignore the learning gap.

SAGES utilized a professional psychometrician to assist us in creating a blue print for the educational program. Through a rigorous process, we identified critical learning points, which then guided the curriculum.  We envisioned two educational products; the first was an on-line curriculum that would be free to all nurses, anesthesiologists and surgeons to learn about the safe use of energy. The second was a high stakes examination.

Today, learners can log on to FUSEdidactic.org and be taught the principles of energy and safe use of related devices. Punching through a series of slides however, while informative, may not lead to an in-depth understanding of the FUSE principles.  Again, using experts in test-writing and validation, we developed an exam that was relevant and distinguished between those who learned the material and others who had not studied.  All test questions were validated by a cohort of 500 surgeons.  FUSE is catching on.  The last issue of SCOPE highlighted that the country of France leased the FUSE didactic, translated it into French, and is now mandating it for surgeons and nurses, and  Germany is considering moving ahead with a similar model.  The United States military is also considering mandating FUSE for all military surgeons.  An increasing number of hospital credentialing boards are discussing requiring surgeons to review specific modules  to retain operating privileges. Similarly, Kaiser Permanente in Southern California is looking to develop an abbreviated FUSE course for their surgeons and nurses.

We have a learning gap;  FUSE can prevent patient harm with a formal educational curriculum that teaches safety.  Hospitals, residency programs, practicing surgeons all know it’s important and should be done.  Three years ago, Past President Michael Brunt called for all SAGES  Board members to become FUSE certified.  Current President Danny Scott emphasized that all Committee Chairs and Co-chairs should also become FUSE certified.  As President-elect, I hope that all 6000 SAGES members will log on and learn about the FUSE Program and consider learning more about the safe use of energy in their operating room.

Selected readings:

All  FUSE articles listed at https://www.fuseprogram.org/about/fuse-elsewhere/

[i] Feldman LS, Fuchshuber P, Jones DB, Mischna J, Schwaitzberg SD; FUSE (Fundamental Use of Surgical Energy™) Task Force. Surgeons don’t know what they don’t know about the safe use of energy in surgery.

Surg Endosc. 2012 Oct;26(10):2735-9.

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Trends in Enhanced Recovery

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By Thomas A. Aloia, MD, Co-Chair SAGES SMART Committee, MD Anderson Cancer Center, Dept. of Surgical Oncology and Nisha Narula, MD Anderson Cancer Center, Dept. of Surgical Oncology

Although enhanced recovery seems to just be getting its footing on the US Surgical landscape, the concept and practice has been well described by Prof. Henrik Kehlet and others since the 1990s. It goes by many names – enhanced recovery after surgery (ERAS), enhanced recovery program (ERP), fast track surgery, and SAGES surgical multimodal accelerated recovery trajectory (SMART(TM)) – but its basic goal, then as now, is to more rapidly return a patient to his/her normal life and functional status.

Strategies:

With this goal in mind there are five strategies employed by most successful programs.  The foundation of any program is patient education and engagement.  The four programmatic pillars then include early mobility, early enteral feeding, multi-modality non-narcotic analgesia and goal-directed fluid therapy.  The tactics that flow from each of these pillars are placed into the preoperative, intraoperative, and postoperative periods. Some key components are preoperative discussion with the patient, selective bowel prep, minimal preoperative fasting, nutritional optimization and carbohydrate loading, regional blocks and narcotic-sparing anesthetic, maintenance of normothermia, minimizing tubes/lines/drains, preventing and treating nausea and ileus, VTE prophylaxis, and prescriptive ambulation orders.

Multiple studies in different surgical specialties, including colorectal, bariatric, gastric, HPB, urology, gynecology, pediatric, and thoracic, across a variety of practice types, have demonstrated the benefits. These studies have found decreased hospital length of stay, lower costs, and equivalent or reduced complications.  Patient-reported outcomes tools are proving that the experience with recovery can be vastly improved.  In oncology patients, time and frequency of return to intended oncologic therapy has also been achieved.

SMART Resources:

For hospitals and surgeons who want to bring these benefits to their patients there are a number of resources available, particularly within the SAGES educational platform. SAGES’ SMART task force, co-chaired by Dr. Liane Feldman at McGill and Dr. Thomas Aloia at MD Anderson (https://www.sages.org/smart-enhanced-recovery-program/), provides protocols that several institutions – MD Anderson, McGill, Case, University of Toronto, UW Medicine, and Methodist – use, as well as guidelines for how to implement them.

Dr. Feldman’s SAGES/ERAS Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery is comprehensive and presents a plan for how to implement ER in a hospital. The ERAS society website (https://erassociety.org/) and the ASER website (https://aserhq.org) also offer evidence-based pathways in bariatric, colorectal, gynecology, pancreas, liver, urology, and head and neck surgery, as well as anesthesia.

Lastly, SAGES has just launched the Enhanced Recovery Implementation Program, a great opportunity to get your ERAS program off the ground.  Geared towards those in the early stages of ERAS adoption, the program includes online mentoring and discussion as well as a course “SMART Enhanced Recovery – Beyond Colorectal,” and workshop “SMART Course for the Team,” on March 23, 2017, at the SAGES meeting in Houston. The online engagement will begin in early February via a closed Facebook Group and continue after the SAGES meeting.  For more information and to enroll, visit https://www.sages.org/enhanced-recovery/implementation-program/ or contact the SAGES SMART Staff Liaison, Linda Schultz, at linda@sages.org.

Enhanced recovery has significantly improved the surgical journey for many patients, but continued work is needed to realize its full potential.  Research on care pathways, patient-centered outcomes, and longer-term recovery should continue in order to prove efficacy and guide inclusion of evidence-based guidelines into future ERPs. In the next few years, we anticipate an expansion of ERPs to most hospitals that perform surgical and other procedures.  By keeping in contact with SAGES (web, print and meetings), surgeons and surgical teams can keep up-to-date on the most current research regarding protocols, audits, and progress.  Enhanced recovery is here to stay and the future is bright.

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