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News By Topic: Surgery Update

An exclusive collection of interview-based surgery articles by leading experts

Read some of our top surgery articles online or download this eBook today!

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Table of Contents15 Preventing SSIs —Deverick J. Anderson, MD, MPH

18 Analyzing the Benefits of Epilepsy Surgery

—John B. Wong, MD

10 Battling Spinal Scoliosis —Frank La Marca, MD

14 Making the Case for Minimally Invasive Breast Biopsy

—Melvin J. Silverstein, MD, FACS

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\Managing Editor Keith M. D’Oria

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Physician’s Weekly™ (ISSN 1047-3793) is published by Physician’s Weekly, LLC, a News Partner of Pri-Med, and a division of M/C Holding Corp. The service is free for qualifying institutions. Please contact us at editor@physweekly.com for more information. Offices: Physician’s Weekly, LLC, 490 State Route 33, Millstone Township, NJ 08535; and 75 Claremont Road, Suite 205, Bernardsville, NJ 07924. Reproduction without written permission from the publisher is prohibited. Copyright 2009, Physician’s Weekly, LLC.

A message from the editorWe at Physician’s Weekly are excited to present you with an eBook dedicated to surgery. In recent months, our publication has featured a variety of news items in this field, focusing on clinical and evidence-based research as well as guidelines. The content in these articles relies on the expertise of our contributing physi-cian authors. We anticipate that Physician’s Weekly will continue to feature news in this field of medicine in the coming months. We hope that you find this information useful in your practice. Please let us know your thoughts by contacting us at editor@physweekly.com.

Sincerely,

Keith D’Oria Managing Editor, Physician’s Weekly

Publication of an advertisement or other product mention in Physician’s Weekly should not be construed as an endorsement of the product or the manufacturer’s claims. The appearance of or reference to any person or entity in this publication (including images) does not constitute an expressed or implied endorsement of the product mentioned. The reader is advised to consult appropriate medical literature and the product information currently provided by the manufacturer of each drug to verify indications, dosage, method, duration of administration, and contraindications.

4

New recommendations from infectious disease experts aim to help clinicians prevent common healthcare-associated infections. Practical recommendations are provided to assist acute care hospitals in efforts to prevent surgical site infections, or SSIs.

Surgical site infections (SSIs) occur in 2% to 5% of patients undergoing inpatient surgery in the United States, but these rates amount to about

500,000 SSIs each year. “While the rate of SSIs is relatively low, the number of these occurrences is high because so many surgeries are performed every year,” says Deverick J. Anderson, MD, MPH. “Each SSI has been associated with 7 to 10 additional post-operative hospital days, which increases patients’ risks for other complications.”

Patients with an SSI are at significantly greater risk of death when compared with operative patients with-

out an SSI. It has been estimated that about 77% of deaths among patients with SSIs are directly at-tributable to the infection. “The costs attributable to SSIs vary depending on the type of operative procedure and the type of infecting pathogen,” Dr. Anderson notes. “Prolonged hospitalizations and the additional therapies required to treat these infections increase costs substantially.” According to published estimates, SSIs are believed to account for up to $10 billion annually in healthcare expenditures.

Prevention RecommendationsA task force appointed by the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and other partners has created a concise compendium of recommendations for the prevention of common healthcare-associated infec-tions (HAIs), including SSIs. The recommendations, published in the October 2008 supplement to Infec-tion Control and Hospital Epidemiology, are designed to help hospitals focus and prioritize their efforts to

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Deverick J. Anderson, MD, MPHAssistant Professor of MedicineDivision of Infectious Diseases Duke University Medical Center

October 26, 2009 • Surgery Issue No. 20

Click here to view this article online.

Preventing SSIs

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implement evidence-based practices to prevent HAIs such as SSIs.

Several practices are important for preventing SSIs, says Dr. Anderson, who was on the panel that created the compendium recommendations. “Much attention has been paid to the administration of anti-microbial prophylaxis in accordance with evidence-based standards and guidelines.” Prophylaxis should be administered within 1 hour before incision to maximize tissue concentration. Agents should be selected on the basis of the surgical procedure, the most common pathogens causing SSI for a specific procedure, and published recommendations. It is also important to discontinue prophylaxis within 24 hours after surgery for most procedures and within 48 hours for cardiac procedures.

The compendium recommendations also provide guidance on prevention strategies for SSIs during the preoperative, perioperative, and postoperative periods (Tables 1 and 2). “More and more hospitals

are getting better at adhering to published guideline recommendations, but patient education during the preoperative period can improve,” Dr. Anderson says. “Patients need to be educated more about their risks for SSIs and informed of the precautions they can take to decrease their risk for these infections. Physicians can provide instructions and information to patients before surgery and describe strategies for reducing SSI risk, such as stopping smoking or con-trolling their diabetes. Providing preprinted materi-als to patients can help. Additionally, elective proce-dures should be delayed until patients improve their modifiable risk factors.”

Get FeedbackAccording to the compendium recommendations, hospitals should measure and provide feedback to providers on the rates of compliance with process measures. “This includes collecting, analyzing, and reporting data on antimicrobial prophylaxis, proper hair removal, and glucose control,” says Dr. Ander-

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son. “Hospitals need to perform surveillance for SSIs and to provide ongoing feedback to surgical and pe-rioperative personnel and leaders. The efficiency of surveillance can be improved by using automated data, and some institutions have been successful us-ing computer-assisted decision-support methodol-ogy. This support is potentially expensive and can be time consuming to implement, but the benefits may outweigh the costs. SSIs may be included as part of accreditation” requirements, so it behooves hospitals to implement policies and practices aimed at reduc-ing the infection rates.”

When implementing policies and practices, hospitals should assess the reduction of modifiable patient risk factors for SSIs. They should also assess the optimal cleansing and disinfection of equipment and the en-vironment, as well as the optimal preparation and disinfection of the operative site and the hands of surgical team members. The compendium recom-mendations also encourage adherence to hand hy-giene and traffic control policies in operating rooms.

Education is ParamountThe education of surgeons and perioperative person-nel about SSI prevention is important, according to the compendium recommendations. Dr. Anderson says staff should be knowledgeable about SSI risk factors, outcomes associated with the infection, local epidemiology, and basic prevention measures. “Sev-eral educational components can be combined into concise, efficient, and effective recommendations that hospital staff can easily understand and remem-ber. The education of staff should include methods to reduce risk to all patients, patients’ families, sur-geons, and perioperative personnel. Just as educa-tional efforts are important when managing patients, they’re also important for the family members who care for them.”

Deverick J. Anderson, MD, MPH, has indicated to Physician’s Weekly that he has worked as a paid speaker for Cubist and has received grants/research aid from Pfizer and Merck. For more information on this article, including references, please visit: www.physweekly.com.

Source: Adapted from: Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S51-S61.

Table 1 Preoperative & Perioperative Recommendations to Prevent SSIsRisk factor

Intrinsic, patient related (preoperative)

Unmodifiable

Age

Modifiable

Glucose control, diabetes

Obesity

Smoking cessation

Immunosuppressive medications

Extrinsic, procedure related (perioperative)

Preparation of patient

Hair removal

Preoperative infections

Recommendation

No formal recommendation: relationship to increased risk of SSI may be secondary to comorbidities or immune senescence.

Control serum blood glucose levels; reduce glycosylated hemoglobin A1C levels to <7% before surgery, if possible.

Increase dosing of prophylactic antimicrobial agent for morbidly obese patients.

Encourage smoking cessation within 30 days before procedure.

No formal recommendation; in general, avoid immunosuppressive medications in perioperative period, if possible.

Do not remove unless hair will interfere with the operation; if hair removal is necessary, remove by clipping and do not use razors.

Identify and treat infections (eg, urinary tract infection) remote to the surgical site before elective surgery.

visit www.physweekly.com 7

References

To access more efforts from the Compendium of Strategies to Prevent Healthcare-Associated Infections, go to www.preventingHAIs.com.

Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S51-S61. Available at: http://www.journals.uchicago.edu/doi/full/10.1086/591064.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250-278.

Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002;23:183-189.

Miner AL, Sands KE, Yokoe DS, et al. Enhanced identification of postoperative infections among outpatients. Emerg Infect Dis. 2004;10:1931-1937.

Mannien J, Wille JC, Snoeren RL, van den Hof S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the nosocomial surveillance network in The Netherlands. Infect Control Hosp Epidemiol. 2006;27:809-816.

Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and postoperative infectious complications. Arch Surg. 2006;141:375-380.

Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706-1715.

Kanter G, Connelly NR, Fitzgerald J. A system and process redesign to improve perioperative antibiotic administration. Anesth Analg. 2006;103:1517-1521.

Source: Adapted from: Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S51-S61.

Table 2 Operative Characteristics & OR Recommendations to Prevent SSIsRisk factor

Operative characteristics

Skin preparation

Antimicrobial prophylaxis

Timing

Choice

Duration of therapy

Surgeon skill/technique

Asepsis

Operative time

Operating room (OR) characteristics

Ventilation

Traffic

Environmental surfaces

Sterilization of surgical equipment

Recommendation

Wash and clean skin around incision site; use an appropriate antiseptic agent.

Administer only when indicated.

Administer within 1 hour before incision to maximize tissue concentration (vancomycin and fluoroquinolones can be given 2 hours before incision).

Select appropriate agents on the basis of surgical procedure, most common pathogens causing SSI for a specific procedure, and published recommendations.

Stop prophylaxis within 24 hours after the procedure for all procedures except cardiac surgery; for cardiac surgery, antimicrobial prophylaxis should be stopped within 48 hours.

Handle tissue carefully and eradicate dead space.

Adhere to standard principles of operating room asepsis.

No formal recommendation in most recent guidelines; minimize as much as possible.

Follow American Institute of Architects’ recommendations.

Minimize OR traffic.

Use a U.S. Environmental Protection Agency–approved hospital disinfectant to clean surfaces and equipment.

Sterilize all surgical equipment according to published guidelines; minimize the use of flash sterilization.

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Despite advances in the treatments for epilepsy, approximately 20% to 40% of patients with the condition are refractory to available antiepilep-

tic medications. These individuals have a substantially increased risk of mortality when compared with the general population. Particularly, temporal lobe epi-lepsy—the most common form of epilepsy—is most likely to be medically refractory. More often than not, physicians continue to keep patients on several medi-cations instead of referring them for further evalua-tion to see if they’re eligible for temporal lobe epilepsy surgery, a procedure that can potentially eliminate or reduce seizure incidence.

Scientific evidence and a statement from the Ameri-can Academy of Neurology (AAN) support the use of temporal lobe surgery to reduce seizures and improve

quality of life. Although it’s estimated that two-thirds of patients become seizure free, this procedure con-tinues to be underused worldwide. Findings from a study published in the December 3, 2008 JAMA dem-onstrated that use of anterior temporal lobe resection may increase the potential for reducing seizures or en-able patients to become seizure-free when compared with those who continue medical management.

Benefits May Outweigh RisksA lack of knowledge within the medical commu-nity about the potential success of anterior temporal lobe resection and/or the stigma attached to “brain surgery” may influence the under-usage of the pro-cedure. Other deterrents may involve potential risks associated with any surgery. Adverse surgical compli-cations for anterior temporal lobe resection have been categorized as either transient—resolving within 3 months—or permanent. They include neurological deficits such as verbal memory decline, postopera-tive infections, and emotion or behavior changes (eg, depression). However, a systematic review of the ef-ficacy and safety of anterior temporal lobe resection was performed by the Quality Standards Subcommit-tee of the AAN. Researchers observed just an 8% rate

Analyzing the Benefits of Epilepsy Surgery

John B. Wong, MDChief, Division of Clinical Decision

Making, Informatics, & TelemedicineProfessor of Medicine Tufts Medical Center

October 26, 2009 • Surgery Issue No. 20

Click here to view this article online.

visit www.physweekly.com 9

of transient complications and 4% rate of permanent complications in over 550 patients who underwent the procedure. Undergoing a complex evaluation may help determine whether the benefits outweigh the po-tential complications.

Randomized controlled trials assessing anterior tem-poral lobe resection have been difficult to perform; the JAMA study was the first to attempt to extrapo-late the potential reduction in mortality afforded by surgery. The Monte Carlo computer simulation model was used to evaluate information on possible surgical complications, quality of life, and the level of patients’ seizures—with 10,000 runs. Our findings demonstrated that operating on patients with an epi-leptogenic zone identified in the anterior temporal lobe increased survival by 5 years, with surgery pre-ferred in 100% of the simulations, when compared with continued medical management. Addition-ally, quality-adjusted life years were increased by 7.5, with surgery preferred 96.5% of the time. The study findings suggest that the benefits could significantly outweigh the risks of surgery in appropriately select-ed patients.

Questions RemainPhysicians managing patients with epilepsy should become more aware of the current surgical options at major medical centers and understand how clini-cal evaluations can help determine surgery eligibility. Further research is needed to identify when physi-cians should consider surgery for patients with tem-poral lobe epilepsy who are refractory to medications as well as those who are the most appropriate candi-dates. Also, additional studies using different meth-ods and technologies should be compared in order to determine which ones are most likely to optimize outcomes (eg, gamma-knife radiosurgery vs vagal nerve stimulation). With more research, the hope is that clinicians will continue to identify the most ef-fective means to reduce the morbidity and mortality associated with epilepsy.

John B. Wong, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report. For more information on this article, including references, please visit: www.physweekly.com.

References

Choi H, Sell RL, Lenert L, et al. Epilepsy surgery for pharmacoresistant temporal lobe epilepsy: a decision analysis. JAMA. 2008;300:2497-2505.

Engel J Jr, Wiebe S, French J, et al. Practice parameter: temporal lobe and localized neocortical resections for epilepsy. Epilepsia. 2003;44:741-751.

Wiebe S, Jette N. Randomized trials and collaborative research in epilepsy surgery: future directions. Can J Neurol Sci. 2006;33:365-371.

Jeha LE, Najm IM, Bingaman WE, et al. Predictors of outcome after temporal lobectomy for the treatment of intractable epilepsy. Neurology. 2006;66:1938-1940.

Sperling MR.The consequences of uncontrolled epilepsy. CNS Spectr. 2004;9:98-101.

Markand ON, Salanova V, Whelihan E, Emsley CL. Health-related quality of life outcome in medically refractory epilepsy treated with anterior temporal lobectomy. Epilepsia. 2000;41:749-759.

Jeha LE, Najm IM, Bingaman WE, et al. Predictors of outcome after temporal lobectomy for the treatment of intractable epilepsy. Neurology. 2006;66:1938-1940.

Sperling MR, Harris A, Nei M, et al. Mortality after epilepsy surgery. Epilepsia. 2005;11:49-53.

1010

Frank La Marca, MDAssistant Professor, Department

of NeurosurgeryDirector, Section of Spine SurgeryCo-Director, Spine Research LaboratoryAssistant Professor, Biomedical

Engineering University of Michigan Health System

visit www.physweekly.com 11

September 21, 2009 • Surgery Issue No. 18

Click here to view this article online.

New surgical treatments are being developed to revolutionize the repair of spinal scoliosis, a fairly

common deformity among adults and children.

Battling Spinal Scoliosis

Scoliosis affects an estimated 6 million people in the United States, according to the National Scoliosis Foundation, and there is currently no

cure for it. The spinal deformity has been shown to significantly impact quality of life. It has been linked with limited activity, pain, reduced respira-tory function, and diminished self-esteem. Although most people will not require treatment, scoliosis is burdensome to healthcare systems. Patients with the condition account for an estimated 600,000 annual visits to private physician offices. Many adults with the deformity will seek pain management with medi-cation but will also need to deal with side effects of these therapies.

“The two most common types of the condition that require treatment are adolescent idiopathic scoliosis

and adult degenerative scoliosis,” explains Frank La Marca, MD. “Most cases in children can be left un-treated, but adolescent idiopathic scoliosis can lead to the development of more severe deformities as the spine degenerates. About 10% of scoliosis cases in adults are degenerative. Adolescent idiopathic scolio-sis has a genetic basis, while degenerative cases usu-ally occur slowly over time.”

Deciding to OperateWhen selecting patients to undergo surgery for scoliosis, Dr. La Marca says there are many aspects to consider (Table 1). “For children,” he says, “we have a good understanding of the type of curves and degrees to which those curves tend to progress to more problems later in life. Children with skeletal

visit www.physweekly.com 11

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maturity who have a 50° curve that has progressed 10° over a year will likely experience severe scoliosis; they require surgery. In borderline cases, bracing and other conservative techniques can be considered, but surgery will be necessary if these strategies fail.”

In the adult scoliosis population, Dr. La Marca says the decision to undergo surgery is not as clear. “It’s currently unknown how fast degenerative scoliosis progresses or if patients will become symptomatic. Typically, operations in adults are performed when they’re symptomatic, unless the curve is severe, so that symptoms can be corrected. The key is to gain a good understanding of patients’ quality of life and

their comorbidities. The impact of osteoporosis and cardiac problems when assessing surgery options for older patients should be considered because opera-tive risks become higher. Surgical candidates must be willing to accept the risks of surgery and commit to the required postoperative management approaches for recovery.” Table 2 provides a checklist to help physicians and patients work through decision-mak-ing processes on surgery for scoliosis.

Table 1 Considerations for Making Decisions About Surgery for Scoliosis

Reasons to have surgery for scoliosis:

• The patient (adult or child) has severe scoliosis that is irreversible and caused by a disease or an unknown factor.

• The patient is a child with a spinal curve >45° that is progressing or expected to progress.

• The patient is an adult with a spinal curve >50° that is progressing or expected to progress.

• The patient (adult or child) has severe scoliosis, and other treatment (eg, bracing) cannot be used or has failed.

• Consider other reasons the patient (adult or child) might want to have surgery for scoliosis.

Reasons not to have surgery for scoliosis:

• The patient’s (adult or child) scoliosis is caused by an underlying factor that can be treated.

• The patient (adult or child) has a spinal curve that is <25° and will have examinations by a doctor every 4 to 6 months to watch for curve progression.

• The patient (adult or child) has moderate scoliosis, but suffers from back pain, which may not be relieved by surgery for scoliosis.

• The patient’s (adult or child) general health places them at significant risk from undergoing any kind of surgery.

• Consider other reasons the patient (adult or child) might want to avoid having surgery for scoliosis.

Source: Adapted from: University of Michigan. Available at: http://health.med.umich.edu.

Table 2 Helping Patients Make A Wise DecisionThe sample worksheet below can help patients in their decision-making process. The worksheet should be dis-cussed collaboratively by surgeons and patients. Circle the answer that best applies to you.

Does scoliosis have a major impact on your life?

Do you (or your child) have scoliosis caused by an underlying factor that can be treated?

If you (or your child) have a severe spinal curve, do you want to wait to see if it progresses?

Do you have a spinal curve >50° that is progressing?

Does your child have a spinal curve >45° that is progressing?

Do you (or your child) have a spinal curve <25°?

Are you comfortable with having surgery?

Does your home or work situation allow you to take the time necessary to recover after surgery?

Has bracing or another treatment for scoliosis been effective?

Do you (or your child) have severe scoliosis that is irreversible and caused by a disease or an unknown factor?

Abbreviations: N/A, not applicable.

Notes: Answers in the above worksheet are meant to give patients a general idea of where they stand on the decision. Patients may have one overriding reason to have or not have surgery for scoliosis.

Source: Adapted from: University of Michigan. Available at: http://health.med.umich.edu.

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

visit www.physweekly.com 13

Minimally Invasive ApproachesMinimally invasive approaches for spine surgery, such as spine fusion, typically focus on managing simple degenerative disease. Outcomes with these procedures often result in effective fusion rates, less blood loss, shorter hospital stays, and faster recovery times. “With scoliosis, however, it’s more challeng-ing to perform minimally invasive procedures,” says Dr. La Marca. “During open surgeries for scoliosis, muscle is dissected from the bone, causing significant muscle damage. With minimally invasive surgery, the degree of muscle damage is minimal. We’re now adapting the techniques being used for simple degen-erative surgery to scoliosis thanks to recent advances in technology.”

At the University of Michigan (U-M), Dr. La Marca and colleagues are using a minimally invasive ap-proach to treat scoliosis that requires very small inci-sions in the skin and no stripping of the muscles. Surgeons can maneuver instruments between the muscle fibers. “The approach has been made pos-sible because of the advancing technology used in neuro-navigational techniques,” says Dr. La Marca. “In addition, new biological materials (eg, synthetic proteins) are used to enhance the fusion of the spine.

We also collaborated with the U-M College of En-gineering in the design of new technologies, includ-ing a special operating table, to help correct spinal deformities even before the instrumentation of the surgery begins.”

Although minimally invasive surgery for scoliosis is still experimental and offered at few medical centers, Dr. La Marca says it eventually could revolutionize treatment for severe cases. “The procedure offers ad-vantages over traditional surgery, especially in terms of muscle damage, scarring, and blood loss. While long-term results are needed, preliminary findings have shown that patients are able to return to work much more quickly. Furthermore, their postopera-tive courses are shorter and their pain is less. As we gather more long-term efficacy data, the hope is that minimally invasive procedures will become the stan-dard of care in the future.”

Frank La Marca, MD, has indicated to Physician’s Weekly that he has worked as a consultant for Medtronic, DePuy Spine, and Stryker Spine. He has also worked as a paid speaker for Medtronic, DePuy Spine, and Stryker Spine as well as Biomet. He has received grants/research aid from Medtronic, DePuy Spine, and Stryker Spine. For more information on this article, including references, please visit: www.physweekly.com.

References

For a press release and video coverage on minimally invasive spinal surgery for scoliosis, go to http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=884.

For more information on scoliosis from the National Scoliosis Foundation, go to http://www.scoliosis.org/.

For more information on scoliosis research from the Scoliosis Research Society, go to http://www.srs.org/.

For more information on deciding whether or not to patients should have surgery for their scoliosis, go to http://health.med.umich.edu/healthcontent.cfm?xyzpdqabc=0&id=6&action=detail&AEProductID=HW_Knowledgebase&AEArticleID=aa115911&AEArticleType=DecisionPoint.

Anand N, Baron EM, Thaiyananthan G, Khalsa K, Goldstein TBJ. Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study. Spinal Disord Tech. 2008;21:459-467.

Guille JT, D’Andrea LP, Betz RR. Fusionless treatment of scoliosis. Orthop Clin North Am. 2007;38:541-545.

Bomback DA, Charles G, Widmann R, Boachie-Adjei O. Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome. Spine J. 2007;7:399-405.

Lonner BS. Emerging minimally invasive technologies for the management of scoliosis. Orthop Clin North Am. 2007;38:431-440.

Son-Hing JP, Blakemore LC, Poe-Kochert C, Thompson GH. Video-assisted thoracoscopic surgery in idiopathic scoliosis: evaluation of the learning curve. Spine. 2007;32:703-707.

14

During an open surgical breast biopsy, patients are often put under general anesthesia, and an incision in the breast is made to remove a tis-

sue sample of the abnormal lesion for examination by pathologists. The incision must then be sutured, which poses risks for infection, bleeding, and scarring for patients. Needle breast biopsy is an effec tive alter-native to the open approach. With this technique, only local anesthesia is necessary. Patients experience

much less discomfort, quicker recoveries, and mini-mal pinpoint scarring. The procedure also saves time and money as open surgical biopsy can cost double or triple the amount of needle biopsy.

With these facts in mind, the American College of Surgeons (ACS) Consensus Conference published guidelines in 2005 sanctioning minimally invasive biopsy as the recommended procedure for diagnos-ing image-detected breast lesions. During this meet-ing, a consensus group I chaired collectively favored a strong supportive statement about minimally inva-sive breast biopsy. We concluded that needle biopsy was the optimal initial tissue acquisition method and procedure of choice for image-detected abnor-malities. There are relatively few patients for whom open surgical breast biopsy should be the initial di-agnostic procedure. In 2006, the American Society

Making the Case for Minimally Invasive Breast Biopsy

Melvin J. Silverstein, MD, FACSMedical Director, Hoag Breast Care Center Hoag Memorial Hospital PresbyterianClinical Professor of Surgery,

Keck School of Medicine University of Southern California

September 21, 2009 • Surgery Issue No. 18

Click here to view this article online.

visit www.physweekly.com 15

of Breast Surgeons issued a statement in accordance with these ACS guidelines.

Data Show That Low Compliance Persists Despite the documented benefits of needle biopsy, a study published in the January 2009 Journal of the American College of Surgeons revealed that near-ly 40% of patients are still receiving open surgical breast biopsy as their initial diagnostic procedure. Considering that only about 20% of the 1.6 million abnormalities detected by mammography turn out to be cancer, the study suggests that many women with benign breast lesions are undergoing unneces-sary invasive diagnostic surgery.

It’s distressing that so many women are going straight to the operating room (OR) for a diagnostic breast biopsy. Relatively few patients need to undergo an open surgical biopsy as their initial diagnostic pro-cedure. For breast cancer, the OR should be reserved for treatment rather than diagnosis. Medical centers and hospitals need to start considering needle biopsy as the standard of care for initial tissue acquisition in both palpable and image-detected abnormalities. This type of policy should be prevalent in more insti-tutions throughout the country.

There are, of course, exceptions where lesions sim-ply cannot be biopsied with a needle because of the

position or other factors, but this occurs in less than 5% of cases. A definitive diagnosis of cancer made using a needle biopsy permits optimal preoperative workup and planning. It gives detailed information about the nature of the tumor. When surgeons know the lesion is cancer before operating, they can more precisely plan the optimal location of the incisions for breast conservation or oncoplastic resection.

How Can We Achieve Higher Compliance?To improve compliance, we need to better inform patients about the benefits of minimally invasive breast biopsy. Patients must be encouraged to be-come their own healthcare advocates; they should educate themselves about available biopsy options and seek out surgeons or radiologists that perform needle biopsies. Referring physicians play an ex-tremely important role; they need to take the time to educate patients and offer guidance about available diagnostic biopsy options before providing referrals. Finally, surgeons must continue to aim for the goal of going to the OR just once to perform the correct therapeutic—not diagnostic—procedure.

Melvin J. Silverstein, MD, FACS, has indicated to Physician’s Weekly that he has no financial disclosures to report. For more information on this article, including references, please visit: www.physweekly.com.

References

Silverstein MJ. Where’s the Outrage? J Am Coll Surg. 2009;208:78-79.

Clarke-Pearson EM, Jacobson AF, Boolbol SK, et al. Quality assurance initiative at one institution for minimally invasive breast Biopsy as the initial diagnostic technique. J Am Coll Surg. 2009;208:75-78.

Silverstein MJ, Lagios MD, Recht A, et al. Image-detected breast cancer: state of the art diagnosis and treatment. J Am Coll Surg. 2005;201:586-597.

Usami S, Moriya T, Amari M, et al. Reliability of prognostic factors in breast carcinoma determined by core needle biopsy. J Clin Oncol. 2007;37:250-255.

Rathka E, Ellis O. An overview of assessment of prognostic and predictive factors in breast cancer needle core biopsy samples. J Clin Pathol. 2007;60:1300-1306.

To access the American Society of Breast Surgeons’ official consensus statement on percutaneous needle biopsy for image-detected breast abnormalities (approved June 12, 2006), go to http://www.breastsurgeons.org/mibb.shtml.