Saturday, July 19, 2008

The tale of the very expensive hernia sac


Posting from the Inxpot in Keystone this morning.....sunny skies, cool mountain air, glorious!

One cannot pick up the newspaper, surf Al Gore's invention, listen to the radio or catch a bit of the news without some dire warning about the expense of medical care spiraling out of control. Despite the feelings of many in Washington, most of us on this end of the scalpel (or stethoscope) really aren't interested in pursuing costly therapies without significant benefits. Sometimes, the academic guys do a bang-up job of dropping the hammer on once promising treatments which have questionable value. Here's a case in point:

Abdominal hernia repair with bridging acellular dermal matrix --- an expensive hernia sac (gotta love that title) is an article in this month's American Journal of Surgery. Before getting into the meat of the article, a lttle background is in order. Let's walk through a very real scenario:

30 year old male is brought to the ED via private vehicle and is unceremoniously dumped at the door. When discovered by the security staff, he is found to be clutching his abdomen, and there is something other than salsa dripping through his shirt. By the time he is whisked into the trauma room, he is cool, diaphoretic, tachycardic, tachypneic, and has a BP in the 60s. In short, he is dying from a gunshot wound to the abdomen.

All of the usual activity ensues --- lines, foley, quick chest X-ray, fluids, and blood. In the OR, he is found to have an injury to the left iliac artery and vein, the ureter, and sigmoid colon. Oh, poop. And he remains pretty unstable to boot. Time for a little damage control surgery --- stop the bleeding, basically, and do everything possible to warm him up and resuscitate him. No sense in dealing with the other injuries, because the more time spent diddling around the higher the chance is he won't survive --- Mr. Freeze is not the desired result, as a cold, underperfused patient in the OR is a patient who may need a celestial transfer. The colon is stapled off and the ureteral injury is drained. There remains one small problem. You can't close the abdominal wall.

When I talk to non-surgical types about this, they usually look at me with the kind of stare that says "boy, you must have gotten your surgical training at the University of Phoenix!" But this is a real phenomenon -- the body is desparately trying to hold onto fluid in an attempt to save itself from shock, and we are giving it as fast as we can to do the same thing. Unfortunately, there is no "perfect balance," and the shock state (for lack of a better way of explaining it) allows a boatload of fluid to escape the friendly confines of blood vessels and into tissues everywhere. This causes at times massive swelling, including of every cell in the abdomen. Putting the chitlins back in at that point is like trying to stuff my rear into an extra small pair of Lycra bike shorts --- it just isn't possible, and it looks pretty ugly while you are trying. If we actually succeed, then the patient will likely suffer from abdominal compartment syndrome --- basically, too much pressure in the abdominal cavity to allow blood to return to the heart and to perfuse the kidneys, and with enough upward pressure on the diaphragm to prevent adequate ventilation. Imagine me turning blue with a pair of XS Lycra bike shorts on, and you've got the picture.

At this point, there are a variety of weapons at the surgeon's disposal. I like to think of them in a stepwise fashion, depending on the severity of the situation. First, to reduce fluid and heat losses, it would be nice to achieve some kind of closure, and the skin will sometimes come together even if the underlying fascia won't --- and we can close it rapidly with a basketful of sharp towel clips (photo from Trauma.org). More often than not, however, we need to leave the abdomen open, and provide some sort of protective barrier covering the noodles. Options here include a VAC-Pack or a sterilized IV bag with towels and drains on top (for ease of use, the VAC is great). These can be readily changed either in the OR or at the bedside, and when the patient's stability allows, the remainder of his injuries can be addressed. These types of patients often consume many hours of OR time.

Eventually, with luck, the patient will improve and reach the point where a more definitive closure is possible. However, getting the fascia closed may be a quixotic task. This means that several months down the road, the patient will be faced with a fairly large abdominal wall hernia --- which means repeat surgery, which itself may be pretty darn difficult.

Now we get to the point of the article. Some enterprising folks have developed products to help us with this problem. They reasoned that if they could develop an acellular substrate that the body would not only not reject, but which the body would incorporate, we could use this material as a bridge to abdominal wall closure, and the patient would heal without a hernia. Cool. While there are a variety of these products, probably the one most well known is AlloDerm.

The authors used this material in a series of patients who were in a bit of a different set of circumstances than our fictional gang banger --- they had a large hernia, had infected mesh, or had an enterocutaneous fistula. Their results, unfortunately, were less than stellar.

Between January 2004 and December 2005, 11 patients underwent complex ventral hernia repairs with bridging ADM. Indications for repair included resection of enterocutaneous fistula, infected mesh, and/or ventral hernia repair. A mean of 175 cm2 (range 8 to 456) of ADM were used. Mean follow-up was 24 months (range 18 to 37). One patient died on postoperative day 20. Eight of the 10 (80%) remaining patients had recurrences, and 7 underwent further surgery for repair. One patient reported laxity but refused repair. The total cost of ADM alone for these 11 patients was $61,926; the cost for the 8 patients having recurrences was $40,776; and the total mean cost was $5,100/patient.
Nice idea, but not all nice ideas have great outcomes. Now, getting back to the top of the post, let's talk about cold, hard cash. This stuff is expensive, as you can tell from the numbers. If physicians were as they are portrayed by the media and folks in the Massachusetts legislature, money grubbing and wholly under the sway of reps passing out pens, this type of data would be totally ignored. BS. This was an expensive product to develop, and it was aggressively marketed to physicians seeking a better solution to a difficult problem. It hasn't worked out well (this is not the first article on this topic I have seen), and most surgeons have stopped using this type of product except in some situations where it is the best of an admittedly lousy set of options ---- because it is expensive and because it doesn't work as well as we had hoped.

Physicians as a whole are neither economically stupid nor so unethical that drug and equipment reps control them like puppets -- those who think otherwise are simply fooling themselves about what goes into caring for patients.

Time to finish my coffee --- I hope you don't think less of me if it is in a "Prozac" mug.