State of the Union: General Surgery Today

An interview with Katherine Fischkoff, MD, Chief of the Division of General Surgery, about clinical trials, the continued expansion of robotic emergency surgery, how Columbia approaches patients considered too high risk elsewhere, and why the future of general surgery may depend as much on decision-making, communication, and access as it does on technical advances.

Looking Again at Old Problems

Last time we talked about the ways general surgery was changing here: robotics in emergency cases, clinical trials questioning when surgery is necessary, and the care of very complex patients. What has moved forward since then?

One of the biggest new pieces is a study that, in some ways, starts with a very old problem: small bowel obstruction.

After abdominal surgery, scar tissue can form and later cause a blockage of the small intestine. For many, the blockage resolves on its own after several days of bowel rest and observation. But for others, it does not. There’s a percentage, like 15% of people, who don’t get better by three days. They end up having to go to the operating room to cut away the scar tissue and open things back up again.

In March, Columbia began enrolling patients in an NIH-funded study, developed with the University of Washington, to test whether IV steroids can help these adults with small bowel obstruction recover faster and avoid surgery. The trial will enroll English- and Spanish-speaking adults and is expected to run over several years.

It’s a big deal because we have been managing small bowel obstructions the same way for decades, for like 50 years. There’s no new treatment…for the most part, there hasn’t been any new way of treating small bowel obstructions forever.

That seems to be a theme in your work: questioning what has become routine. Is there another example of that?

Lipomas are one example, and I know how silly that sounds. They are common, generally benign fatty masses. People usually get them removed because they are bothersome or uncomfortable. The traditional operation is simple enough, you know, we make an incision and cut the lipoma out.

But I was always saying in clinic, “I’m going to take it out, but just so you know, you’re trading the lump for a scar.” A lot of times the lipoma is not that big. And you never know how somebody heals. And some people keloid terribly.

Are you developing a new method to remove lipomas?

The first Columbia study we tried used radiofrequency ablation to try to melt lipomas. It did not work as hoped. It basically took like a big juicy grape and turned it into a shriveled raisin.

So we pivoted to liposuction. That allows us to flatten and contour the area through a tiny opening, then pass the radiofrequency catheter through that same opening so the lipoma is less likely to recur. The whole point of this is to do it through one tiny little needle hole.

How common is recurrence with lipomas?

Lipomas have a capsule, and if that capsule is left behind, the lipoma can grow back, so recurrence is certainly an issue. At the end of the day, we hope that liposuction provides the cosmetic benefit patients want, while RFA addresses what liposuction alone can’t do.

We’re still trying to get funding for the trial, but we’re getting emails a couple times a week from people all over the world. From people with lipoma diseases who are covered with small masses. What are you going to do in those cases, cut them all over? It’s terrible.

Robotics in Emergency Surgery

Columbia has been an early leader in robotic emergency surgery. Has that work continued to evolve?

Yes, and now the team has data to support what we have been building. A resident recently completed a paper looking at Columbia’s experience with robotic emergency general surgery, which is one of the earliest and largest experiences in the country.

What we were able to show is that we did it completely safely. Our complication rate is either at or better than national averages.

And emergency surgery usually carries more risk than the elective version of the same operation. We’re getting great outcomes and doing it safely and minimally invasively. And there’s a lot more we can do in the emergency setting with the robot than we used to be able to.

What kinds of emergency cases are now being done robotically?

For gallbladders, appendixes, and hernias, robotic surgery has become pretty routine for the group. Especially when a patient presents with an incarcerated or obstructing hernia. Some bowel obstructions and emergency colon operations are still handled selectively. We use laparoscopically most often, but more are moving toward robotics as experience grows.

With colons, we may not be doing all of those robotically, but we’re doing them minimally invasively. Even emergency colectomies for colon perforation or diverticulitis are also beginning to move in that direction.

We’re certainly doing more minimally invasively than we were before, and the robot makes many of our operations easier.

What has emergency robotics taught you that elective robotic surgery could not?

Emergency surgery doesn’t invite experimentation because patients are acutely ill. Sometimes, you’re a little more worried about applying new technologies because you just want to get the patient into the operating room and get them out safely.

We have such a depth of experience and access to robot that what we’ve learned is that we can safely take what in other places might be considered risks. But at our institution, we can do them safely.

When Other Centers Say Surgery Is Too Risky

You have also talked before about caring for patients who were told elsewhere that surgery was too risky. Is that still a major part of the practice?

It is, because we’re embedded in a hospital that cares for very sick patients. Heart failure patients, transplants, patients with pulmonary disease, complex comorbidities who may not have straightforward surgical options elsewhere.

Someone with severe gallbladder disease who has been managed with drains because other teams considered surgery too dangerous, and they’re symptomatic and miserable. Here those patients can be evaluated by a team. I have a handful of patients every month where we work very closely with transplant medicine and cardiologists and pulmonologists for people who are very high risk.

There’s just so many examples of where that experience and that teamwork comes into play. Recently, I had a patient with heart disease severe enough to require transplant evaluation and also active gallbladder inflammation. Before he could even be considered for transplant listing, we had to fix the gallbladder issue.

There is something about Columbia that allows you to push those boundaries. We have phenomenal ICUs [Intensive Care Units] and phenomenal cardiologists and pulmonologists who will carry you through to the end.

Does your background in critical care change how you evaluate risk?

Yeah, totally. A hundred percent totally.

Critical care experience gives you a more intimate understanding of what can go wrong and how sick a patient can become. It also creates long-standing relationships; we know each other so well from those ICU settings and you have this level of trust. I know what you can do and you know what I can do.

When a referral comes in from cardiologists for a heart failure or transplant patient, or VAD [ventricular assist device] patients who also need hernia repair, or gallbladder surgery, or something else. Many other places would consider these too risky. But we ask: “what is the risk, what is the alternative, and can the system support the patient safely through the operation?”

Aggressive is not quite right, because it sounds like being a cowboy. We are never reckless. It is informed risk-taking backed by institutional depth.

Survival, Values, and the ICU

Last time we talked about looking more deeply at what survival means for each patient. Where does that thinking fit now?

Some of that work is happening through critical care, we’re studying parts of ICU care that have always been treated as routine. It is underappreciated how much we starve people in anticipation of procedures.

ICU patients often need a tracheostomy, a feeding tube, interventional radiology drainage, or a trip to the OR. Each time, they may be made NPO [a medical term from the Latin nil per os, meaning the patient is not to be given food while in the hospital] from midnight, sometimes for procedures that happen late in the day or get delayed. Those hours without nutrition add up.

Of all the interventions we do in the ICU, nutrition is probably one of the most important things—nutrition, antibiotics, and physical therapy. Everything else is just like time and luck. In one study we’re asking whether ICU patients who are already intubated and sedated truly need feeds held for long stretches before procedures.

Another ICU study is focused on communication with families. We’re studying how best to support that role as the conduit of information and care. It’s also part of the same larger question: how to make high stakes care more humane.

Where does palliative care fit into good surgical and critical care?

Ana Berlin’s [general surgeon and palliative care specialist] work is around aligning surgical care with patient values, especially for patients with existing DNR [Do Not Resuscitate] orders.

Historically, patients going to the operating room were asked to suspend a DNR order for surgery. But that approach kind of misses things—like asking what is acceptable during the operation, what should happen afterward, and how plans should change once the immediate procedure is over.

Dr. Berlin’s work has helped create a more organized system of required reconsideration around DNR orders for the perioperative period, so the preoperative, intraoperative, and postoperative plan stays aligned with what the patient actually wants.

We are pushing the envelope. We are doing high-risk things, but again, not being a cowboy.

When Surgery Is Not the Only Answer

You have also studied conditions where patients may not always need an operation. What has changed there?

Appendicitis has already changed. A major study that included roughly 1500 patients showed that most cases of appendicitis can be treated with antibiotics, with similar outcomes in the first year. We now routinely offer eligible patients a choice between antibiotics and surgery.

Patients get a QR code for a video that explains appendicitis, the options, and uses what the study taught about patient preferences.

If the most important thing to you is to get back to work right away, you should take antibiotics instead of surgery. If the most important thing to you is to never have to worry about your appendix bursting ever again, you should have surgery.

The goal is to give patients the information they need to choose the tradeoff that fits their life.

Are there other diagnoses where that same question is being studied?

Diverticulitis is one. The team recently finished enrolling patients in a trial focused on uncomplicated diverticulitis, a common condition that can range from mild recurrent attacks to emergency perforation requiring surgery and sometimes colostomy.

When I was a resident, the teaching was fairly simple: after three attacks, surgery. But removing part of the colon is not a small operation, and recurrent diverticulitis does not affect every patient the same way. So, really three and that’s it?

For one person, recurring attacks may be manageable. For another, travel, caregiving, work, or fear of another episode may make them want surgery. The study is designed to better understand when surgery should be offered for uncomplicated diverticulitis and how patient priorities should enter that decision.

The Next Layer of Surgical Decision-making

When we do this again next year, what do you hope has moved forward?

I think the role of AI really in thinking about how to make decisions is the next question. Bowel obstruction is one of the first areas where we’re thinking about applying it.

How do we amass the enormous amount of data that we have on patients and help make the best decision for them—for surgery, not surgery, now, later, that kind of thing?

The way we use the appendectomy video, I’d also like to build that kind of resource for more common diagnoses, so patients can begin learning before they enter the clinic. We created a similar video for salpingectomy in English and Spanish. Whatever we can do to push stuff to people that’s not in a brochure format would, I think, be really useful.

We’re going to keep looking at the old ways of doing things and try see if there are better ways with all that we know now. These will be long studies, but it’s just so easy to sort of keep doing what you know how to do. And we’re thinking about whether there are different ways of doing them to make life better for our patients.