American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Gastrointestinal Complications More Common in Critically Ill COVID-19 Patients

El Moheb M, Naar L, Christensen MA, et al. Gastrointestinal Complications in Critically Ill Patients With and Without COVID-19. JAMA. 2020.

Knowledge of the frequency and symptom patterns of abdominal complications related to COVID-19 infection has potential value for surgeons who may be called upon to assist in the care of such patients and provide advice regarding surgical interventions. This article sought to determine whether gastrointestinal complications were more common in patients with COVID-19 infection compared with non-COVID patients who had critical illness of similar severity.

The authors reported results from an analysis of more than 200 patients who were hospitalized with severe COVID-19 infection in a single academic medical center; a cohort of similar size comprised of critically ill patients without COVID-19 infection was then chosen. Using propensity matching, the authors compared the frequency and severity of gastrointestinal complications between the two patient cohorts. As with other reported studies of critically ill COVID-19 patients, the study patients were older; more frequently male; and often had comorbid conditions such as diabetes, hypertension, heart disease, and chronic renal disease.

The analysis showed that 74 percent of the COVID patients had gastrointestinal complications compared with 37 percent of the non-COVID patients. The most common complications were elevated liver enzymes and ileus; mesenteric ischemia requiring intervention was observed in 4 percent of the COVID group. The authors noted that the high levels of expression of angiotensin-converting enzyme receptors on intestinal epithelial cells could help explain the frequency of gastrointestinal complications. Ileus and mesenteric ischemia could be explained by the discovery of widespread microvascular thrombosis noted on examination of gastrointestinal tissue examined at autopsy or after surgical excision.

Although limited by the data from only one center, this study shows that gastrointestinal complications are common in severely ill COVID-19 patients and provides important data to guide additional research.

Retrospective Analysis Examines Predictors of Chronic Pain after Laparoscopic Inguinal Hernia Repair

Forester B, Attaar M, Chirayil S, et al. Predictors of chronic pain after laparoscopic inguinal hernia repair. Surgery. 2020.

Forester and coauthors report a retrospective analysis of nearly 1,000 patients who underwent laparoscopic repair of inguinal hernia at a single institution over a 12-year interval. Standard scoring systems were used to quantify pain and quality of life over a follow up interval of five years. The authors emphasized the fact that high-quality data are available for quantification of risk for chronic pain in patients who have had open inguinal hernia repair. With the increasing use of minimally invasive approaches for surgical management of inguinal hernias, data that focus on patients who have had laparoscopic repairs have potential value.

The data analysis showed that chronic pain was diagnosed according to standard scoring system criteria in 6 percent of the cohort. Factors that were found to be significant predictors of chronic pain on logistic regression analysis included younger age, female sex, elevated preoperative pain scores, prior inguinal hernia repair on the same side, higher ASA class, use of multifilament polyester mesh, and intraoperative placement of a urinary catheter. Patients with chronic pain had longer durations of postoperative analgesic usage and longer recovery intervals prior to return to normal activities to daily living.

The authors concluded that their data offer insights into factors that may have importance in preoperative patient counseling. The data suggest that use of lighter weight meshes could potentially reduce risk for chronic pain.

New Paper Examines Ethical Challenges and Policy Solutions to Surprise Billing in Surgery

Sheckter CC, Singh P, Angelos P, Offodile AC, 2nd. Surprise Billing in Surgical Care Episodes - Overview, Ethical Concerns, and Policy Solutions in Light of COVID-19. Ann Surg. 2020;272(4):e264-e265.

This article provides useful perspective on the ethical challenges and potential policy solutions to the problem of surprise billing in patients who undergo surgical procedures. The authors begin with a clarification of differences between balance billing (when an out-of-network provider presents a bill for the difference between in in-network and OON fee) and surprise billing that occurs when a patient receives a bill from a provider who was thought to be in-network but was not. Surprise bills are usually large because they are not influenced by market forces.

Recent survey data cited by the authors disclosed that nearly 70 percent of respondents expressed worry about their inability to afford unexpected medical expenses and nearly 80 percent supported legislation to prevent surprise billing. Additional data cited in the article showed that unexpected billing occurred in 20.5 percent of surgical care episodes. Patients desire high-quality care at an affordable cost, and surgeons want fair compensation for the level of service rendered. It is important that an informed choice is made by the patient so that surprise billing can be avoided and trust in health care providers can be preserved.

The authors provided two interesting patient scenarios that examined the ethical challenges and demonstrate that avoidance of surprise billing will provide support for the provision of care with an emphasis on justice for the patient. The authors then presented the critical elements of ethically sound policy decisions that could provide a useful remedy for the problem of surprise billing. These include comprehensive protection of patients' economic welfare; restoration of in-network fees to a fair, market-based level; and a credible means of audit and enforcement. The authors noted that staffing disruptions related to the COVID-19 epidemic have increased the risks for surprise billing, and this fact hopefully will stimulate the needed policy changes.