A conversation with Katherine Fischkoff, MD, Chief of the Division of General Surgery, about the latest in general, emergency, and acute care.
Let’s dive into what’s happening in general and acute care surgery right now. As part of our Future, Today series, we ask: What is the most futuristic thing happening in surgery today?
We have incorporated robotic surgery into all surgical care. We’re also running some clinical trials trying to change the standard. For example, the traditional approach to lipomas has always been to remove them surgically. But given that it's typically an operation for cosmesis—and comes with overhead like coming to the OR, fasting beforehand, and leaving a scar—we thought there had to be a better way. Radiofrequency ablation technology has been used extensively in other tumors, like thyroid and liver, so we thought we could apply that to lipomas to avoid surgery and scarring.
Another area we’re focusing on is providing safe surgery to patients who might not otherwise be able to have it. For example, I recently saw a lady with a very complicated hernia, but she’s had three heart operations, lung disease, and other medical problems. No one else would touch her. But because of our experience with critical care—and our relationships with cardiologists, pulmonologists, and anesthesiologists—we can offer surgery to people that others might not consider. That’s a huge benefit for our patients.
That’s impressive. Can you explain what critical care means in this context?
We take care of people in the ICU. If someone’s had an operation and they’re sick after, they need intensive care, and we manage those patients. That includes patients who’ve had heart surgery, lung transplants, liver transplants, or who come in with surgical diseases that make them really sick, like bleeding or bad infections. We have specialty training in caring for critically ill patients, including managing ventilators, blood pressure medications, and severe pulmonary disease.
We also know how to manage patients on ECMO and operate on them if necessary. Not everyone walking in the door needs that level of care, of course, but knowing we can handle it gives patients peace of mind that they’re in good hands.
Is there anything new or evolving in critical care at Columbia?
We’re constantly evaluating how we care for our patients in the ICU. Technology has allowed us to do incredible things, like ECMO, for example, but one of the new frontiers in critical care is minimizing the impact of an ICU stay on a patient and their family. That means addressing delirium, weakness, and getting people out of the ICU as quickly as possible. These may sound basic, but they’re innovative because we’ve spent the last 50 years decreasing mortality rates, and now we’re focused on keeping people alive. We don’t want them to have PTSD after an ICU stay. That’s where a lot of our focus is now.
It sounds like that overlaps with palliative care and how it’s integrated. Could you talk about that?
Palliative care is definitely part of critical care, especially in the ICU setting. A lot of palliative care is complex symptom management, but it’s also about having access to those conversations preoperatively for high-risk operations. That way, we can talk about what happens if something goes wrong. It’s important to be well-versed in these difficult conversations.
Are there any research initiatives or clinical trials in critical care that stand out?
A lot of ICU research right now is focused on reducing complications and side effects of being in the ICU. For example, improving pulmonary outcomes for patients on a ventilator, reducing pneumonias and pressure ulcers—basically, helping patients get out of the ICU alive and in good shape.
You mentioned that we’re leading the way nationally on robotic emergency general surgery. Could you expand on that?
Traditionally, robotics was mostly incorporated into elective procedures, but in 2023, our group performed 40% of all the robotic emergency cases in the country, with excellent outcomes. All of the benefits of robotics in elective cases also apply to emergencies, and sometimes even more so because robotics offers better views and dexterity in difficult cases. Thanks to access to robotic technology, we’ve been able to push that envelope significantly, and we’re working to publish our experience.
What are the most common emergency cases you treat?
Appendicitis, gallbladder disease, emergency hernias, and bowel-related emergencies like obstructions, clots, and ischemia. We also see perforated ulcers and diverticulitis, though medications have reduced those cases—basically, any intra-abdominal emergency.
Shifting to patient experience and safety, have there been any changes in protocols or practices that improve outcomes?
As the chair of the Quality and Patient Safety Committee, I’m always working on that. One of the benefits of doing a lot of clinical trials is that we’re constantly learning and updating our practices. For example, with bowel obstructions, we’re leading a clinical trial on how to manage them, and we think we can get people better faster without surgery. We also review complications regularly, which helps us adjust protocols to keep patients safe. Communication is key, especially handoffs [between different shifts of caregivers], and our group is really strong in that area. It’s not just about reducing infections and complications; it’s about the intangibles that make a difference for patients.
Looking ahead, what are your priorities for the next year or five years?
Personally, I want to increase our elective surgery volume. One of the things I love about my job is taking care of the community population. We give all of our time and effort to ensure they get the best possible care at Columbia. I’m proud that we can offer the same high-level care to everyone who comes through the door. Going forward, I want to expand what we can offer and make sure the community knows they can come to us for excellent care, and I’m excited to grow that. Of course, we’re always working to stay at the forefront of new developments, too.
Before we wrap up, could you give us a quick overview of some of the other research projects underway in your division?
In addition to our scar-free approach to removing lipomas using radiofrequency ablation, we’re also doing outpatient clinical trials on diverticulitis—looking at whether patients need surgery or not—and trials on appendicitis to decide between surgery or antibiotics.
And finally, what’s your favorite part of your job?
I guess it’s simple: being able to treat the community and offer the amazing care that Columbia provides. That’s the thing I’m most proud of.