Background
Diversity, equity, and inclusion have been an intentional focus for SAGES well before the COVID-19 pandemic and the coincident societal recognition of social injustices and racism. ...Longstanding inequities within our society, healthcare, and the surgery profession have come to light in the aftermath of events that rose to attention around the time of Covid. In so doing, they have brought into focus disparities, injustices, and inequalities that have long been present in the field of surgery, selectively affecting the most vulnerable.
Methods
This White paper examines the current state of diversity within the field of surgery and SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) approach and effort to pave the way forward to meaningful change. We delineate the imperative for diversity, equity, and inclusion for all. By all, we mean to be inclusive of the diversity of gender and sexual orientation, race, ethnicity, geography, sex, and disability in the field of surgery.
Results
SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric.
Conclusion
True diversity, equity, and inclusion within a surgical organization is vital for its longevity, growth, relevance, and impact. Unfortunately, the absence of DEI limits opportunity, robs the organization of collective intelligence in an environment in which its presence is critical, contributes to health inequities, and impoverishes all within the society and its value to all with whom it interfaces. SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric. Strategies like those highlighted in this White Paper, may be within our grasp and we can learn yet more if we remain in a place of humility and teachability in the future.
Purpose
Females suffer higher rates of operative recurrence and chronic pain following groin hernia repair. Guidelines recommend minimally invasive (MIS) groin hernia repair as the preferred approach ...to reduce these adverse outcomes. It is unknown what proportion of females receive MIS hernia repair. Therefore, our goal was to investigate adoption of evidence-based practices in groin hernia repair using sex as a biological variable.
Methods
Retrospective cohort study of adults undergoing elective groin hernia repair (2014–2019) within a statewide quality improvement collaborative. Primary outcome was surgical approach. Multivariable logistic regression was performed to analyze the likelihood of undergoing MIS hernia repair. Secondary outcomes were 30-day adjusted rates of clinical and patient-reported outcomes (PROs). PROs included regret to undergo surgery among patients who completed post-operative surveys.
Results
Among 23,723 patients, the majority (90.7%) were males. Compared to males, females less often underwent an MIS surgical approach (37.4% vs 45.1%,
p
< 0.0001). After adjustment for patient and clinical variables, females remained significantly less likely to undergo MIS groin hernia repair (aOR 0.88, 95% CI 0.80–0.97). Adjusted clinical outcomes were not different between males and females. Among 4325 patients who completed post-operative surveys, adjusted rates of regret to undergo surgery were higher among females (12.9% vs 8.5%,
p
= 0.003).
Conclusions
Even after adjusting for differences, females were less likely to receive guideline-concordant groin hernia repair and were more likely to regret surgery. Understanding the behaviors of surgeons who treat females with groin hernia may inform quality metrics to promote best practices in this population.
Background
To date, no studies have investigated how the preoperative management of clopidogrel, an irreversible antiplatelet agent, influences the outcome following minor operative procedures. The ...purpose of this study is to determine if clopidogrel use within 7 days of inguinal herniorrhaphy increases the postoperative risk for bleeding-related morbidity or mortality.
Methods
A retrospective chart review was performed of 46 patients on clopidogrel who underwent inguinal herniorrhaphy from 2004 to 2008. Patients were grouped based on the last administered dose of clopidogrel; <7 days (A) and ≥7 days (B).
Results
Of the 46 patients, 20 were in group A and 26 were in group B. No significant differences in operative blood loss, perioperative transfusion requirement, postoperative bleeding complications, intensive care unit (ICU) requirements, mortality, or 30-day readmission/reoperation rates were demonstrated between patients in groups A and B. Patients in group A had a significantly increased postoperative admission rate (65% vs. 15%,
P
= 0.0002) and increased mean hospital stay (1.0 vs. 0.15 days,
P
= 0.003). However, urinary retention, pain management, and the monitoring of other conditions accounted for over 80% of these admissions. One patient in group A (5%) developed a postoperative hematoma, which is consistent with the complication rate seen in the general population after inguinal herniorrhaphy. Overall, no difference in admission secondary to hematoma or postoperative bleeding was demonstrated.
Conclusion
Clopidogrel use within 7 days of inguinal herniorrhaphy did not increase the risk for perioperative bleeding complications. No mortalities, readmissions, or ICU requirements occurred, regardless of the timing of clopidogrel cessation. The increased risk for hospital admission and length of stay seen in group A is likely to be attributable to nonbleeding-related patient factors rather than clopidogrel use. Thus, it may not be necessary to interrupt clopidogrel therapy prior to inguinal herniorrhaphy in high-risk patients.
Background Our purpose was to determine optimal management of and outcome after umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites. Methods A retrospective chart ...review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at The Mount Sinai Medical Center from 2002 to 2008. Univariate, multivariate, and Kaplan-Meier analysis was performed. Results Twenty-one patients had refractory ascites: 15 presented with incarceration and 6 with spontaneous umbilical rupture. The mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation, and 5 developed ascites-related wound complications. Follow-up at a mean of 36 months demonstrated a 20% mortality rate due to liver disease; 5% required liver transplantation and 6% had a recurrent hernia. In addition to diuretics and albumin, perioperative management of ascites consisted of preoperative transjugular intrahepatic portosystemic shunt (TIPS; n = 6), postoperative TIPS ( n = 2), and closed-suction drains ( n = 7). The wound complication rate was 17% in patients who underwent preoperative TIPS versus 27% in patients who did not undergo preoperative TIPS ( P = NS). TIPS placement postoperatively controlled ascites adequately without additional complication in 2 patients. In this series, use of closed-suction drains did not appear to decrease ascites-related complications. Spontaneous umbilical rupture was an independent risk factor for adverse outcome. For patients presenting with umbilical rupture, preoperative TIPS and semi-elective repair appeared to improve perioperative and 36-month outcome as compared with emergent repair. Conclusion Preoperative TIPS in conjunction with semi-elective repair when feasible appears preferable, particularly for patients with spontaneous umbilical rupture. The lower than anticipated mortality rate was attributed to institutional experience and to the multidisciplinary approach to patient care.
