Expert panelists debated two important topics during a Panel Session on the final day of Clinical Congress 2024, “The Great Debate: The Challenges of Rib Fracture Fixation and Who Should Manage Specialty Surgical Complications.”
Rib Fracture Fixation
The first topic was the optimal course for addressing rib fracture and whether surgical intervention was preferrable.
David E. Meyers, MD, FACS, an associate professor in the Department of Surgery at McGovern Medical School at The University of Texas Health Houston, argued for the surgical stabilization of rib fractures, noting that the data do not support its use in most cases.
He began by discussing recent research in this area, where there is a dearth of high-quality data examining surgical stabilization of rib fracture (SSRF). Some observational studies, which are prone to more bias, had indeed shown that SSRF is useful, especially regarding flail chest—but two randomized controlled trials suggested another important finding.
“The overwhelming majority of rib fracture injuries do not have clinical flail chest, and these studies suggest that patients who have their ribs fixated do the same as those who do not—and sometimes they do worse,” Dr. Meyers said.
Alicia J. Mangram, MD, FACS, senior medical director for the trauma surgery program at HonorHealth in Phoenix, Arizona, took the opposing approach, wherein she argued that there are emerging indications for surgical fixation.
Pain, liberation from ventilator, flail chest, and especially mechanical problems such as a patient feeling popping or clicking from their ribs on respiration—these are all indications that can be aided by SSRF, Dr. Mangram suggested.
She provided an overview of several techniques available to surgeons, such as minimally invasive muscle-sparing thoracotomy and robotic fixation, noting that some research has suggested that early surgical fixation leads to less pain and better outcomes, improvements in pulmonary function for older patients, and cost effectiveness for hospitals.
“All fractures will heal with time, and we have many techniques for stabilizing a rib fracture—splinting, cast immobilization, and so on—but surgical fixation is a definitive solution to the problem,” Dr. Mangram said.
Management of Surgical Specialty Complications and Emergencies
The second part of the session focused on an increasingly relevant topic for general surgeons and abdominal surgery specialists—the optimal surgeon to manage complications and emergencies for specialty procedures.
Colorectal
Arguing for the specialist management of colorectal complications, Kristina Booth, MD, FACS, an assistant professor in the Department of Surgery at The University of Oklahoma Health Sciences College of Medicine in Oklahoma City, asked the core question: In a life-or-death situation, does it matter who is on call?
The answer, she said, is yes. While general surgeons are competent and at times necessary to take care of emergencies, the nature of skill acquisition, borne through repeated exposure and education, makes it so that a specialized colorectal surgeon likely will see superior outcomes.
Citing a long-term study, Dr. Booth said, “When a bowel specialist is operating on a bowel disease or a bowel emergency, there is a decrease in mortality, a decrease in hospital length of stay, and increased likelihood of a minimally invasive procedure, which is better for the patient.”
On the other side, Justin L. Regner, MD, FACS, a general, surgical critical care, and trauma surgeon at Baylor Scott & White Health in Temple, Texas, argued that a general and acute care surgeon is the best surgeon for colorectal emergencies, focusing on the pragmatic and logistical side of the issue.
Dr. Regner said that in the US, medical care is rationed and constrained by resources—and surgeons are highly valued but limited resources themselves.
“I think the better question is when is the best time to perform emergency colon surgery, not who is the best surgeon,” he said. “The surgeon who can get the patient to the OR and achieve source control of an infection or address the perforation is the right surgeon.”
Because there are many more general surgeons available to address these issues, they can be the best surgeons to address colorectal emergencies and complications, he suggested.
Bariatric
In the bariatric portion of the session, Fadi Balla, MD, FACS, a minimally invasive general and bariatric surgeon at Kaiser Permanente Westside Medical Center in Hillsboro, Oregon, argued that a specialized bariatric surgeon is better suited to manage potential complications.
Noting that general surgeons are capable of handling bariatrics, he echoed Dr. Booth by saying that specialization matters—with more procedures comes more comfort and better outcomes.
It is especially important now with bariatric surgeries growing at a rapid pace in the US and around the world. While general surgeons will have familiarity with Roux-en-Y bypass and sleeve gastrectomy, evolving techniques such as duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S), may involve complications that a bariatric surgeon is defter at handling, he noted.
And, importantly, “The case doesn’t end at the end of the case. If a patient can be transferred after a life-saving operation, call us to manage them afterward,” Dr. Balla said.
The other side of this debate was led by Matthew E. Kutcher, MD, FACS, co-director of the surgical intensive care unit at The University of Mississippi Medical Center in Jackson, who agreed that specialists should manage their own complications whenever possible, but there are other things to consider at a high-level view.
He said that in Mississippi, there are a very low number of bariatric surgeons, and because bariatric surgeries are increasing, the concomitant rise in complications and emergencies will require handling by general and acute care surgeons.
“Acute care surgeons will and do manage bariatric complications and should be well-trained to do so,” he said. “And the need for acute surgical management of short- and long-term bariatric complications will only increase over time.”
Dr. Kutcher said that acute care surgeons are familiar with most complications, such as bleeding, incisional surgical site infection, and so on, and can work together as part of a practical and necessary care team to address the growing complication burden of bariatric surgery.
Watch the debates on the virtual platform.
