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Speaker 1 (00:00):
All right everyone. Welcome to Hernia Talk Live. This is Dr. Shirin Towfigh. As you know, we are here every Tuesday. You can follow me on social media at Hernia Doc, on Twitter and Instagram, and this is being SimulCast on Facebook Live as well as for those of you that join us via Zoom. Today’s amazing guest is probably one of the most unique surgeons we will be talking to. His name is Dr. David Santos. I’ve had the pleasure of knowing Dr. Santos for many, many years. He is a general surgeon, but he works at a cancer center. So he is a surgeon at the MD Cancer Center, sorry, MD Anderson Cancer Center in Houston, Texas. And you can follow him on Twitter at Santos MD Surge. And we’ll learn a little bit more about Dr. Santos once he says hi to us. Hi.
Speaker 2 (00:54):
Hello. How are you doing?
Speaker 1 (00:55):
I’m good. I’m really excited that you said yes during this pandemic cause I know Texas is a little bit.
Speaker 2 (01:04):
Yeah, we’re getting
Speaker 1 (01:05):
Into problems a little bit.
Speaker 2 (01:07):
Yeah. But everywhere else, I think that we’re all in it together, for lack of a better word for it. It’s kind of doing what it does. This is true. Yeah. So before we talk I do work at MD Anderson Cancer Center, but I do have to say for compliance reasons, all opinions expressed are my own. They’re not necessarily that of MD Anderson Cancer Center. And I’m here just kind of speaking as a surgeon of nine years of experience and just going to tell you a little bit about my practice. So all tweets are my own. None of this is like <laugh> institutional. It’s just me speaking my opinion.
Speaker 1 (01:43):
I love it. Well, your tweets are amazing, and the work you do is amazing. And I told you this before, I would love to have your job. It’s such a unique, unique job because you’re a general surgeon, which means you get to do everything general surgeons do. But by default, every single patient that you treat has a cancer diagnosis. Is that about right? That’s
Speaker 2 (02:05):
Correct, yes. So in order to be treated at MD Anderson Cancer Center my understanding is that you have to have a cancer diagnosis or being followed for a pre-malignant condition or being screened for some cancer, preventative cancer prevention screening. So those are the reasons you’d be followed at MD Anderson. But 95% of my patients have some sort of established cancer diagnosis that’s either in remission and treated or having active treatment. So a lot of my patients are on chemotherapy protocols, experimental protocols. Some of these protocols don’t have names. They have different kinds of alphabet soup.
Speaker 1 (02:44):
So that’s very different in that. So you treat emergency situations that are related to cancer, but a big chunk of what you do is abdominal wall and hernia related.
Speaker 2 (02:58):
That’s correct. So that’s something that actually developed much more in a much more sophisticated manner after 2017. So I started around 2014, 2015, and I was an MIS surgeon at a Southern California Health Maintenance organization. That’s all I’m going to say. So
Speaker 1 (03:16):
Very well, very well trained one, I must say.
Speaker 2 (03:19):
Yes, thank you. Fellowship director. But I really did walk out on my fellowship very comfortable with laparoscopic IPOM and a little bit more comfortable with laparoscopic, laparoscopic bilateral inguinal. That is actually a very hard procedure to learn. I realized a year after being in it, and I was like, man, this is going to take me at least two years to learn this Well, and sure enough, it was something that you just had to kind of keep doing. I’m not actually the first person to do a laparoscopic bilateral inguinal at MD Anderson, but I was certainly one. It was something I did more frequently than the other person. No,
Speaker 1 (03:58):
I’m kidding. Really?
Speaker 2 (03:59):
Yeah. So they would kind of walk in my room and go, what are you doing? I’m like, oh, I’m doing a bilateral tap. And they’re like, wow. And I’d be like, yeah, but you do whipples. Really, this is nothing compared to what you do. But it was just an interesting, because their surgical oncologists, at least that in that era were more they were more open surgeons. You know what I mean? They weren’t necessarily into laparoscopy per se. I
Speaker 1 (04:21):
Think that’s still true. That’s still true. They oncologic surgeons, surgical oncologists are more adept with laparoscopy just because surgical training before they do this fellowship has become so heavily involved in laparoscopic and robotic surgery. But as a general, I think still the majority do mostly open surgery.
Speaker 2 (04:43):
I would say that’s generally true. I know that for this recent class of surgeons that are the assistant level, associate level, we’re all kind of in that robotic revolution right now. So some of them are doing distal pancreatectomy, doing hepatectomy, whipples, things like that robotically. So we’re starting to move in that direction.
Speaker 1 (05:02):
So full disclosure, Dr. Santos was one of our fellows from many years ago. I can’t believe it’s been that long.
Speaker 2 (05:08):
Nine years.
Speaker 1 (05:10):
Nine years. Wow.
Speaker 2 (05:12):
Almost a decade.
Speaker 1 (05:13):
Wow. I believe I was his fellowship director at the time, and I’ve always kept in touch with you. I thought you were just an amazing person. I really enjoyed your positivity, and then you went and because of your training and got this really amazing job that I don’t know that any other cancer center really has someone like you. Is that right?
Speaker 2 (05:41):
So my understanding now, it may have changed since my recruitment in 2015, but at the time I was being recruited to MD Anderson. There was no freestanding cancer center that had just a specific general surgery department to do general surgery, acute care. I like cancer, but it’s not my path. I didn’t necessarily want to be a surgical oncologist. And a lot of people that kind of go to these cancer centers want a pathway to be a surgical oncologist. That was never in my plans. And so I think that was one thing that was very attractive to them is that I like being a general surgeon. I like handling what comes through the door. And so it was a mutually beneficial kind of relationship. I missed being in an academic environment where you work with people that are the best of the best in their field and it just fit a glove. And I have never looked back. This has been one of the best jobs I’ve ever had.
Speaker 1 (06:36):
So for those, most people know MD Anderson, but it’s the top or if not the top one or two, it’s among the top one or two. There’s always a debate in the United States, and therefore possibly therefore the world very, very advanced. The stuff you guys do from an oncologic standpoint is really neat, but that means that you as a general surgeon need to also understand not only the treatment plan, but also the complications associated with that so that you could address that.
Speaker 2 (07:09):
That’s correct. So they already did have a very strong abdominal wall reconstruction history with Dr. Butler and his group. They do primarily open repairs and they do a lot of repairs with strattice, kind of their preferred Mesh that they use biologic biological Mesh. So I try to do work in my lane, really do a lot of laparoscopic procedures for ventral hernia repairs. But I realized right around 2015, 16, some of these things were not adequate for <laugh> for the type of hernias that I was seeing. So lap IPO is really fun for me, but not so much for the patient. Yes, they hurt after that procedure. And there’s complications associated with Mesh also? Yes. Some of these cancer patients have a very specific constellation of hernias. So they’ll have an associated stoma with a parastomal hernia with it. Okay.
Speaker 1 (08:05):
So we had Dr. Paula here last month where we talked about parastomal hernias can be very complicated.
Speaker 2 (08:12):
Yes. So that is something, something I realized additionally, like IPO is a nice procedure for this kind of middle of the road hernias where you can put ’em together. But you and I both know that can sometimes turn into a bridge procedure and it really hurts them sometimes. So I really tried to look at different options. You want to know how I actually got into robotics was through the urologist. It really wasn’t driven by me. Oh,
Speaker 1 (08:38):
Nice.
Speaker 2 (08:39):
Yeah, I was pretty much, I don’t think I need to learn robotics. It’s just not my thing. I can do this on my s, I’m pretty good at it. But some of the urologists come in and say, Hey, can you repair this inguinal hernia? At the same time I do this prostatectomy? And first of all, I had to make sure that was safe and it is. Then I had to realize, wait a minute, I cannot put this Mesh in robotically. I need a skill set. So that’s really what kind of started me down this pathway and because of them, and I own them a debt of gratitude to really get me into these advanced repairs.
Speaker 1 (09:09):
So for the audience md, you’re right. Dr. Butler and MD is very well known. He’s a plastic surgeon by training, and so a lot of his philosophy is tissue based which is a very plastic surgeon kind of way of doing things, whereas general surgeons have been doing a lot of Mesh based and synthetic based, but plastic surgeons are not trained in laparoscopy or robotics. So do you feel that operating in CAN patients with cancer that laparoscopy or robotic surgery and I, I’m going to use those interchangeably because they’re just two different toys that we have that offer minimally invasive surgery. Do you feel that that’s an especially useful tool in cancer patients or not necessarily? It’s very highly variable.
Speaker 2 (10:02):
So it’s highly variable depending on the situation. I’m finding that cancer patients have, like I said, constellations of hernias. So colorectal will oftentimes have a midline incision and they’ll have a parastomal component or if they have stage three or stage four disease, so they have a liver met, that’s the most common reason to do a hepatectomy is a me colon met to the liver. They’ll have this extension. So they’ll go midline and they’ll go sideways, which is called a Makuuchi incision. She’ll goes transversely across the rectus. As you can imagine, that’s a uncommon incision and you can get hernias through that. Yes, prostatectomy, direct inguinal hernias, that actually happens quite a bit. And so I ask them, what do you do with this? And they pretty much just leave them alone. So either sometimes they’ll put a stitch, some of them have tried Mesh, but for the most part, majority of them will just leave them alone and they inevitably developed some sort of hernia later, which is hard to repair MIS.
Speaker 2 (11:00):
So that’s kind of the other thing that you see. Things that I’m not necessarily comfortable with are flank hernias and things that happen after. Those are things I don’t know how to do yet, but that’s where Dr. Butler’s group is really good because they do those posterior column hernias really well. So I think I work well with them. Now in terms of MIS being useful for cancer we have a PEC program. So basically how Intraperitoneal, Onlay chemotherapy, and they will often and gastric as well, and sometimes they have mets to the peritoneum. They will oftentimes ask us when we’re doing their hernia repair to do a diagnostic peritoneal lavage, and if they see anything kind of suspicious, they’ll biopsy it at the same time. So in that respect i s is very useful because you can sometimes detect cancer recurrence. I personally have not detected a recurrence, but the oncologists know what they’re looking at. They’re like, yeah, that’s something we need to pick.
Speaker 1 (11:56):
So we had, I’ll share with you the screen here. We had a bunch of questions put in and they’re very similar. I’ll go through three questions. They’re very similar in their question. One is, do you find that the approach to hernia repair is philosophically different in patients with cancer? What’s your protocol for performing hernia surgery in an oncologic patient and does a patient’s five year survival affect your surgical decision making?
Speaker 2 (12:27):
I would say the short answer is
Speaker 1 (12:29):
How are you different? How could others learn about going into a cancer, sorry, going into a hernia operation knowing that they’ve had a cancer procedure, a cancer operation, cancer diagnosis, whatever it could be. What’s your thought process with that?
Speaker 2 (12:50):
So
Speaker 2 (12:53):
Technically the procedures that I offer are not different than what you would offer. They, they’d be the same technical procedure. Really the difference is the decision making of when you provide certain repairs and when you don’t. I would say you have to have a little bit of knowledge about cancer and the cancer biology to know what would happen. So you gave, before we went online, we were talking about carcinoid, for instance. So carcinoid is one of these things. The only treatment really is just to keep removing it. So if it’s a patient in which they’re going to do, say a right hemi-colectomy, but they’re relatively young and they know that they’re probably going to have to go back and do more extirpative surgery. This is maybe a patient I wouldn’t close with a Mesh. This is some one. I maybe do a primary repair.
Speaker 2 (13:38):
If it is one that required a Mesh and that didn’t need a component separation, then I would probably do an underlay. I personally don’t like strattice against Bell, I feel like, or biologic against Bell. I feel like it sticks. So mm-hmm preferentially, if I can put it retro muscular, I will. So I guess the first decision making point is the cancer biology, is it something that’s going to keep recurring? The second decision making point is, okay, so if it does recur, are they going to do anything about it? So are they going to do a liver resection? Are they going to go do a completion APR? The third thing is the patient preference. So you know, might run into a patient that maybe doesn’t have a long time to live, but a lot of times what we do as hernia surgeons is quality of life surgery. So the yes for them, these patients might value having a hernia free survival more than a lifelong survival. Does that make sense? Basically, they would rather have their repair and live a higher quality of life knowing that they’re not going to necessarily survive longer than five years. In that case, it’s like, okay, well that makes sense. In those patients, I would offer them a repair.
Speaker 1 (14:54):
Yeah, that’s a really good point. So at Cedar Sinai, we have a wide range of patients, and I get involved in some of the more complicated ones because of that decision making. Patients who’ve had surgery before, if there’s a cancer related operation, you have to think, is this patient going to need another operation? And if so, I don’t want them going through, I don’t want them messing up my repair basically so that I’m very protective of my hernia surgery. So if I’m putting Mesh in, which let’s say is a standard for abdominal wall incisional hernia, you have to put Mesh, we discussed this couple of hernia attacks before. The recurrence is well over 50%, usually in the 60% range. And that that’s just an unacceptable numbers. So we do recommend that you use synthetic Mesh, but there are a lot of options. There’s like absorbable Mesh there.
Speaker 1 (15:55):
Well, to use Mesh, there’s absorbable synthetic, and there’s this hybrid Mesh. The problem with Mesh is if you need another surgery and it’s open, sorted, then they have to go through your Mesh and going through the Mesh can either disrupt your hernia repair or you can infect the Mesh. Correct. Or you can expose the Mesh now to the contents and maybe that could cause a complication. So I’m always thinking, okay, the patient with carcinoid, that’s a type of cancer where they need maybe four or five, six operations during their lifetime because it just kept, comes back, you go, and resect again, comes back resect. That’s like the treatment often. And so I use either a biologic or what’s called a hybrid Mesh, so it’s part biologic, part synthetic. So it gives a good repair, but the risk of exposing it and causing a Mesh infection, et cetera with the next surgery is low.
Speaker 1 (16:56):
Actually, there’s another question, but I like what you say about the five year survival, because the average surgeon who sees a patient that has let’s say a 10%, 20%, 30%, five year survival, but otherwise looks good. So let’s say they’re eating and so they don’t look sick, but we know that the tumor is a late stage tumor and they had their surgery the average surgeon would probably not operate because they feel mm-hmm. Right? They don’t feel comfortable. They feel that it’s high risk, but the surgery itself necessarily isn’t high risk. You’re just adding an operation during the patient’s survival, which may improve their quality of life.
Speaker 2 (17:45):
And oftentimes that’s kind of what they want. They want improvement in their quality of life. And that’s a lot of my discussion in the office. It’s like, it’s interesting when you work at a tertiary, tertiary level cancer center, because a lot of them have accepted their mortality. They know that they may not have long on the earth. So their discussion is sometimes different. It’s not necessarily a depressing, sad discussion. They know what they want. They’re very focused on trying to live their life. And so it’s your job as the physician to facilitate that if the surgery that you’re going to offer them is relatively low risk. So I’ll give you an example. So sometimes these patients with cirrhosis, <laugh>, you know what I mean? Yes. You got to make sure that that’s the one that, that’s kind of my hard stop usually is cirrhosis. So if they have cirrhosis that’s from a portal vein thrombosis, that really has to be repaired before I move forward.
Speaker 2 (18:39):
But if they can get it to a level where the IDs is minimal and I can stay outside of the abdomen, I may offer them an onlay knowing that it’ll temporize them for a couple of months, and if that couple of months is what they have left on the earth, then I have contributed some sort of quality of life to them, even though I would’ve not necessarily done that operation otherwise. So it’s really, you know, have to have a lot of, I think arrows in your quiver when you have cancer patients. So you have to have different types of techniques for different patients and accept different levels of risk. So I think that’s kind of like a lot of what I do with the consultations with these cancer patients.
Speaker 1 (19:16):
That’s a good point. Different levels of risk. It’s all relative. So what I tell my residents is life before hernia. So if a patient’s life is at stake and they have a hernia focused on the lifesaving portion of the operation, the hernia can come later. But at the same time, if you’re improving quality of life and you’re not increased and they’re able to survive the operation, have a enjoy that quality of life, then maybe it’s not the perfect hernia repair. Maybe it’s not like the one that you would do in a young healthy athlete, but it would be something that would improve the quality of life. I think people need to understand those people that watch this hernia talk is that we have a lot of tools in our toolbox, open, laparoscopic, robotic, and then within that with Mesh, without Mesh, different types of component separations and tissue repairs we have wide range of Mesh product products. What do you use for Mesh? What are your different options that you have available?
Speaker 2 (20:24):
So since I prefer robotic intramuscular, it’s always going to be some midway polypropylene Mesh. To me, that’s really what it is.
Speaker 1 (20:32):
Standard spot normal. I’m sorry. Yeah.
Speaker 2 (20:36):
Yes,
Speaker 1 (20:36):
The standard spot. Normal, yeah,
Speaker 2 (20:38):
Yeah, pretty much. Is the Mesh infection rate higher? It can be, but you know what, to be honest with you, even though you, I’ve had infections where you have synthetic Mesh, I’ve been able to salvage them with antibiotics. I haven’t necessarily had to go back and remove the Mesh a lot of the times in terms of, oh, here’s a special thing about cancer patients. Sometimes they’re neutropenic. All right, so there isn’t
Speaker 1 (21:05):
Neutrophils count is very low,
Speaker 2 (21:07):
Less than two.
Speaker 1 (21:09):
When that, oh, less than 0.2 is the definition
Speaker 2 (21:13):
Less than one is the less than one definition, which means,
Speaker 1 (21:19):
So that only makes them higher risk for infection. Does it also affect their healing?
Speaker 2 (21:23):
Definitely affects their healing. So earlier in my tenure there I was using sometimes the hematologist will say, I really need this lymph node biopsy, so I need you to take it out of their armpit. And I’m like, their white count is near zero. I don’t feel like this is going to be a good idea. And sure enough, when you just do that little tiny incision, sometimes it doesn’t heal. And when I would look at that, I’d be like, man, if I do this in a hernia, this may not heal depending on their white count there are some things that I learned that you can do to raise their white count. So I learned a little bit about some of these agents that use to elevate white blood cell counts such as neupogen and colony stimulating factors and so forth. With that, you have to, so
Speaker 1 (22:09):
You use that when your hernia patients
Speaker 2 (22:12):
Sometimes depending on whether or not, oh, they’re in, that’s the other thing. You have to catch them during in the middle of their cycles. So oftentimes they’re having lots of rounds of chemotherapy, but they’re why blood cell count will rebound. So you kind of have to catch him right when, so they may look really bad when you see ’em in person, but then when by the time surgery rolls around, their white skill count may have rebounded or their oncologist might be able to raise their white blood cell count to promote healing. So that’s another trick that I’ve learned. It’s like you have to really be multidisciplinary with cancer patients. Like they’re right, they’re your patient, but they’re also the oncologist patient. So you really have to share ownership. And I found that relationship to be to beneficial because we talked a little bit about survival.
Speaker 2 (22:59):
A lot of things that patients that I thought would not have good survival are actually having great survival because we’ve had some advances in chemotherapy in particular immunotherapy. So nibs and mabs, as I call ’em, didn’t exist <laugh> when I was a medical student, it was not something that existed. But these targeted drugs that work, for instance on melanoma with very little side effect to the patient and a lot of cure, there’s a lot of things that you didn’t think would necessarily be curable are now starting to be kind of curable. So because you don’t necessarily have that fund of knowledge as a surgeon, it’s really valuable to talk to your oncologist to figure out these side effects. And so that’s another thing I would encourage. If you see a patient on a trial, you probably want to talk to their oncologist about the side effects, how you can work to get their why blood cell count optimized
Speaker 1 (23:49):
Communication is key when you’re in this multidisciplinary treatment of the patient. We have a question about Mesh removal. What’s the thought of Mesh removal? What thoughts go on your mind when treating patients that have cancer and may need a Mesh removal?
Speaker 2 (24:06):
So my philosophy is this, try not to get in that situation where you have to have Mesh removal. Kind of my thought prevention is probably better prevention’s, probably better than getting in that situation. So if they have a smallish size hernias a lesson to, obviously you don’t put a Mesh. If they have a colostomy take down, for instance, at the same time that they have a ventral hernia where they need some sort of repair that’s a patient, I would probably put a biologic Mesh. If they have no further surgical options, the oncologist will not offer them any other procedures, but they have this wide hernia I’ll put a synthetic and it might do a robotic. But yeah, I try not to get in that situation at all.
Speaker 1 (24:53):
Here’s another question for you. Is there an issue with placing Mesh in patients with cancer? So can it affect their cancer itself or can it affect their treatment options? What do you know about that?
Speaker 2 (25:18):
Meaning with the implants onto the Mesh? Is that maybe what this question is referring to? Yeah I would say, to be honest with you, I have not noted an association between Mesh placement and cancer but I do think there are appropriate places not to use Mesh. So if you have a patient that has a peritoneal type disease or something that has potential to move to the peritoneum, maybe not the best idea to put a Mesh in that patient, it might be better to use some sort of onlay technique and that would be kind of what I would do.
Speaker 1 (26:00):
There are some people that claim that can Mesh can cause cancer. Have you ever heard of that?
Speaker 2 (26:07):
No, I have not heard of that. But I would imagine that there are some people that believe that
Speaker 1 (26:14):
The reason why they believe that is, I believe there was one paper that a patient had a Mesh complication. It required involved an introcutaneous fistula and by definition of Mesh infection and I think they had a skin cancer in the area of the inflammatory process. So I mean that doesn’t mean the Mesh causes cancer. If you had the fistula, regardless of whether there was Mesh there or not, that may have been a risk. As we see there’s like same happens when you get a skin burn. When you get a burn. That burned skin is at risk for cancer in the future. Correct. There’s a term for that. Something’s ulcer. Is that a marginal, is that a marginal ulcer?
Speaker 2 (27:01):
Yeah, it’s a marginal ulcer.
Speaker 1 (27:03):
Yeah.
Speaker 2 (27:04):
Yeah, bird, right. Oh man, that take me back to 2007. I don’t remember that <laugh> God, but yeah, but no, yes,
Speaker 1 (27:12):
<laugh>, it’s been a while since I’ve treated
Speaker 2 (27:14):
A, yeah, no, but people will see associations but not, they won’t necessarily identify causation and they kind of mix up the two. Yeah, there might be an association, but it doesn’t mean that that was a causative factor for that. In my nine years as a surgeon, I can say with confidence, I do not know of any association between Mesh causing cancer.
Speaker 1 (27:41):
And you work in a cancer center?
Speaker 2 (27:43):
Yes. I mean now I could be wrong, but I have not seen that. No,
Speaker 1 (27:47):
I mean I always say we don’t know everything but that one for now at least we’ve been using Mesh for longer than I’ve been alive. So yeah, you would see a lot more issues if that were the problem. But let’s go back to that question because I think it’s a useful question, which is that do you putting Mesh in, does that maybe delay their need for chemo or can you irradiate the area after Mesh is placed? What do you know about that?
Speaker 2 (28:21):
So I used to think irradiated tissue would be difficult to operate in. I think it causes more scarring per se, but placing Mesh, I think if I knew that it was a high risk area for healing because it would have poor vascularization and so forth and there was a higher risk for infection, that’s a patient I would probably consider putting a biologic Mesh in. Let me see, in terms of what was the other thing about that? Like you said if
Speaker 1 (28:54):
Is it possible to irradiate the area after Mesh was placed?
Speaker 2 (28:59):
If it was somebody that I knew that was going to get multiple rounds of radiation, I would probably put a Mesh that would be less risk in terms of infection. So it would probably be a biologic. But again, if I had no options, for instance, I did a parastomal hernia and I had to deal with poly poly prepared to peritoneal hernia repair. Yeah, I never thought I’d have to bust that out, but I totally did because it was the only option that I had for this patient. I have never put a biologic in that situation. So I was really only, the only choice I had was a mid-weight polypropylene synthetic Mesh because it’s not described with biologic. He hasn’t described it with biologic. I wasn’t about to do that to a, and I accepted a little bit of risk, meaning Mesh infection and so forth. But again, it goes back to that whole idea that none of these patients are going to be perfect. There’s always going to be some sort of issue and you’re going to have to know how to manage and manage complications well and make sure that they are handled in an appropriate fashion. That’s pretty much it.
Speaker 1 (30:01):
Right. The next question is you kind of talked about it, but maybe you can be more specific. How does chemotherapy and or radiation affect healing for hernias after hernia surgery?
Speaker 2 (30:16):
So immunosuppressive chemotherapy, things like cyclosporine, things that decrease your absolute neutrophil count are things you have to and things you have to watch out for. Also, VEGF inhibitors like bevacizumab, so that’s Avastin, that’s a common drug used in things like colorectal cancer and other cancers as well. Five FU kind of the same thing. They work by impeding healing, but as I said, some of these other, so if you have a patient that’s on that you want to time it when their Nader has passed and they’re ready to have surgery because their absolute neutrophil count increases if it doesn’t increase to about one and that’s just a new institutional thing we use one it, it’s really doesn’t have a lot of high level data, but for us an absolute neutrophil count less than one is kind of an indication that we should give them some sort of white blood cell count booster.
Speaker 2 (31:12):
So if we can get it above one, then you can operate on this patient. Probably in terms of patients that have immunotherapies, really the side effect for immunotherapies changes depending on how that antibody was derived. So if it was derived from a human, so usually the manifestation in these patients is going to be systemic. So any kind of problem’s going to be skin rash, pulmonary, things like that, and it doesn’t really necessarily affect wound healing so much. Any kind of MAB where it’s just from a wrap for instance, then that usually does not affect wound healing as much. It’s more, again, they’re systemic things, but you have to look specifically at some of the side effects. The main culprit that a lot of people point to is bevacizumab because it’s a VEGF inhibitor which impedes wood healing. Radiation itself, I haven’t really found to be too much of a problem other than sometimes it’s just very scarred and you can’t define the planes very well. So in that case you kind of have to figure out, all right, I can’t really do a retrorectus or figure out the planes. I might just have to do an underlay and that’s how I handle radiation.
Speaker 1 (32:20):
And is there a certain amount of time after chemotherapy that you wait before, let’s say they’re done with their chemo and during that process a hernia developed, how much time do you wait until their last cycle you schedule them for surgery? Minimum.
Speaker 2 (32:42):
So the wisdom of older surgeons it seems, and just from review, reviewing charts and working in my department, they seem to wait about four to six weeks, but that seems arbitrary. There doesn’t seem to be a specific reason for that. Maybe practice based learning because maybe that’s what they have learned throughout their practice. But in terms of a high level, this is when you should do it. I don’t think there’s echo points to that because you have to figure out whether or not delaying their chemotherapy is worth it. Sometimes they can’t wait too long and so you do have to accept, hey, yeah, I may have some impaired wound healing because this person can’t wait. So if their oncologist is saying I got to do it at two weeks, then that might be the time. My feeling is this chemotherapy tends to give patients a functional status decline and that’s very important for us as surgeon. So if they can’t walk or they’re wiped out, that’s really going to hurt their post-operative recovery because we want them to walk, we want them to not get some of these post-operative complications. And so that’s a
Speaker 1 (33:43):
Really good point.
Speaker 2 (33:45):
So if you need to operate on these patients, you have to time it in between when they’re going to be strong enough to recover. So one thing I do is if they can’t even get up on the table, then probably not a good idea to operate on this pa. If they’re in the office and I ask if they’re in a wheelchair and they can’t climb up onto the examining room table, that’s probably a good sign that they won’t get up after surgery. Additionally, they oftentimes arrive in my clinic in wheelchairs, so you have to be very honest with them because our place is big, so they put ’em in wheelchairs to get ’em from place to place. So yes, functional status is very important, a very important discussion I have to have with them. Something I kind of ran across recently that never really occurred to me, but chemotherapy can cause something called chemo brain that is a very real thing.
Speaker 2 (34:37):
And so I noticed when I would talk to some patients, they would be very foggy. I mean they look normal, but they would be talking in, it’s almost as if you would repeat something like eight times and they wouldn’t really get it. And I’m like, why are you, I mean are you just old? I mean what’s going on? Sometimes chemotherapy can affect the way that effect that patients mentate. So I can’t figure out why they’re not comprehending what I’m saying. I oftentimes ask them, so how, what’s your experience with chemotherapy been? Have you had problems orienting, have you, things like that. So that is something that’s unique to these patients on chemotherapy that I think a lot of surgeons take into account that mentation may not necessarily be a hundred percent. So that’s the other thing I want to say about that.
Speaker 1 (35:21):
That’s a good point. So you’re okay operating, let’s say the chemotherapy is done and then four to six weeks later, assuming they’re otherwise okay to have surgery. What about in between cycles? If it’s something a bit more urgent, do you do with that you just work with the oncologist to see if they can maybe delay the next cycle and how serious that would be?
Speaker 2 (35:45):
Yes, absolutely. Because they’re the ones that really know the mortality rates on that they run their trials. So they’re on sometimes very strict trials. So if they have to wait a certain amount of time, then you have to they have to take ’em off the protocol and that delays their therapy. So you have to make sure that it’s not going to interfere with their cancer treatment because that’s why they’re there at a tertiary center. They’re there for that chemotherapy protocol, but they can’t help it. Sometimes they get diverticulitis, sometimes they get an incarcerated hernia. But the main thing that I have found at least is that you can’t predict a certain time period, but you can say, Hey this is what I need to do, the oncologist and you then negotiate and then you accept a certain level of risk depending on the complication that could occur.
Speaker 1 (36:36):
Right. On that note there’s another question that’s relevant, which is what are your tricks for either predicting or handling ascites when doing a hernia repair or lymphatic leak? So let’s say, I don’t know, patient that needs a hepatobiliary surgery or some type of pancreatic surgery and last time they had surgery they had ascites or they currently have ascites. Ascites is fluid collecting inside the abdomen can cause not only pressure, but any fluid it can leak into the crevices of hernia repairs and so on and wounds. What do you have tricks for that?
Speaker 2 (37:19):
So a lot of times you have to screen ahead of time and think to screen ahead of time with imaging to see how much ascites actually have and you look temper in time how close it is to the repair that you’re having. So even if they have kind of a little ascites and the scan is old, I tend to get a image that’s a little bit closer to the time that they want surgery to make sure that they don’t have massive ascites because it can hide. Also, you want to treat the underlying condition. So sometimes they’re going to have some sort of portal vein thrombosis. So say they got splenectomy and distal, one of the splenectomy is one of the culprits that can cause portal vein thrombosis. And so the treatment for that is to get rid of that clot.
Speaker 2 (38:05):
Reading the operative node is very important. So any kind of surgery that kind of messes with the portal vein, so like a Whipple, a distal pancreatectomy splenectomy, some sort of a coker man some sort of, it’s that maneuver where they put it around the highland liver, I forget the official name, but they put a tourniquet Pringle, sometimes a Pringle maneuver. Anything that messes with the portal vein, you kind of have to think in the back of your head, could this person <laugh> embarrassing? You have to think about whether or not the person has some sort of portal vein thrombosis. And so then you go down your pathway, you’re like, all right, do they need an ultrasound? Do they need a CT? And if you diagnosis, which sometimes you can because your specialists are not thinking necessarily like that, they can be treated with anticoagulants for a time, have their ascites resolved and then go and do the surgery. Now, in terms of lymphatic leak, I haven’t encountered that too much. I think I see that more when I do mesenteric lymph node biopsies because you’re working with CHIME and you’re working with the mesentary, but I haven’t have a good way to predict lymphatic leak. I think the best thing is just to understand the patient’s history, understand what they might be at risk for depending on the type of surgery that they have, and make sure you diagnose it early before you operate on them.
Speaker 1 (39:24):
Yeah, they’re just so fascinating how much you’ve learned how much you’re able to share with us as well. I’m learning a lot. There was a patient that I was asked to be involved with, and that was actually my question for you, which was about the ascites because the original procedure did cause a lot of ascites and that meant that the second surgery would may have the same kind of issue. And then I don’t like to put, so my philosophy is in general, I don’t like to put Mesh inside the abdomen. I like to do it either basically away from the organs, away from the organs that you bowel for multiple reasons. And also with cancer, I just don’t like to do that. And then the ascites issue, there’s a risk of Mesh infection, there’s a risk of wound breakdown, which will expose your repair. You want to make that hernia repair so that it doesn’t break down from the leakage.
Speaker 1 (40:25):
Also adds a lot of extra abdominal pressure. So it’s taking your hernia repair then trying to stretch it out. So all of those are factors that I take into account when I do these operations. And I feel that maybe the average general surgeon who does hernias in addition to a thousand other different operations maybe doesn’t necessarily take that into account and then you fall into a problem. Do you think that patients that have a serious cancer diagnosis and then need a hernia repair, do you think they should be seen by someone like you as opposed to their local general? Should they shop for a hernia specialist or is that just overkill?
Speaker 2 (41:12):
I don’t think that’s overkill at all. <laugh>, because as a general surgeon, a lot of the reason we become surgeons because we’re attracted to an endpoint, we see a problem, we want to fix it. It’s a nice neat little package and we have a plan for it. But when it becomes complicated like this and it becomes multidisciplinary, I’ve seen a lot of my peers go, I don’t want to touch that. You know what I mean? But I’m kind of unique in this respect because I kind of like the
Speaker 1 (41:40):
Mental, I would want to touch that actually <laugh>,
Speaker 2 (41:43):
What I like the mental journey, because part of the reason I became a doctor is because I do have a little intellectual curiosity. So yes, I think that’s why I’ve got a perfect for this job because you’ve really got to think two or three steps ahead. A lot of the times, a lot of what I do is prevention. It’s not so much <laugh> much to just fix this hole in the bucket, so to say. It’s like, look, there’s this bucket, there’s a hole in it. You have five different ways to fix it. What’s going to best work for this person? And so you have to dig history, et cetera. So in terms of ascites, I do encounter ascites, but it’s usually in the setting of an emergency surgery. So it’s usually somebody who has ascites with incarcerated bell. We’ve all been there and my colleagues are sometimes what Santos is the best one on <laugh> on the team to handle this, which is not necessarily some, I don’t want to say it’s a dump, but I do have some expertise on this and this is how I handle that patient with ascites.
Speaker 2 (42:44):
So that’s an open surgery that’s not minimally invasive, that’s not nothing. It’s open because you’re going to have to evacuate ascites. So when you evacuate the ascites, yes, you repair the hernia most of the time. That’s going to be an underlay for me because it’s oftentimes not something you can close primarily, and you do need some sort of Mesh buttress. Cause I think it’s going to recur if you just sew it. So you need to put some sort of buttress. But here’s the kicker, you have to realize your liver physiology after this is done because this patient is not done after you do this procedure, they get thirsty, they get hepatorenal syndrome. And so if you are not on top of your medicine, you can’t just go, oh, just let medicine handle that. They’re not as aggressive as you. So you have to make sure that you understand this liver physiology that’s happening after you handle this patient with ascites. And sometimes they have ascites because they have lymphoma. So then at the same time you’re dealing with their chemotherapy protocol and whether or not you got to give them Neupogen. So it’s a little medicine-y, but medicine-y with some aggressive tactics, so to speak.
Speaker 1 (43:47):
Yeah, I think what’s cool about surgeons is that we are I, we don’t know as much as internal medicine doctors in the nitty gritty, maybe necessarily, but we know a lot of internal medicine because we need to integrate that into the care of our patients before and after surgery in addition to the surgery that we do. I think that’s fascinating. It’s one of the reasons why I love what I do is because and I feel like you’re, you do the same is that I work with a lot of specialists. I work with the internal medicine doctors. One patient has Factor V Leiden mutation. One patient has this other medical diagnosis that I need to read up on and learn. And then at the same time, I work with a lot of different surgical specialist urologists, orthopedic doctors. So in residency, I didn’t get to see necessarily what they did, but now that I’m working with them and collaborating, it’s really fun and I like learn new things. Yeah, I
Speaker 2 (44:49):
Like it. I conduits that’s, that’s a good example. So ilio
Speaker 1 (44:52):
Conduits. Oh, that’s a hard one.
Speaker 2 (44:54):
Yeah, I see a lot of those. And so I’ve had to actually play in other surgeon’s backyards, so to speak. I have to learn yes procedures a little bit. So I noticed I started getting a few more ilio conduits because they get these parastomal hernias, but when you get,
Speaker 1 (45:09):
They’re very difficult to repair because it’s a large, there’s multiple ways of making an ilio conduit. So these are people who don’t have a bladder, let’s say for bladder cancer, right? Yes. And so the urologists very interestingly make a bladder, which is basically a bag to store your urine and they make it from the small intestine. Correct.
Speaker 2 (45:35):
So they take these ureters, which are from the kidney, and they anastomosis to this new bladder. But when you get in there, it all looks like chicken. I mean <laugh> really just like, you dunno what you’re looking at. And so I had to learn different techniques. So I had to number one, watch the video and realize that they passed this, ureter underneath the sigmoid. So that’s one thing. And then use your bag of tricks, dig into your backpack, find the arrow and go, Hey, what can I use to identify this ureter? I guess I can use I C G, right? So these are things that you know have at your disposal. And I probably can do it robotic because it’s easier to place Mesh much in a much more fitted fashion than if I were to do it laparoscopic, at least to me. But these are, and then again, it comes to that constellation. There’s that ventral hernia that’s associated with this parastomal at the same time. And so you kind of have to fit your Mesh to that. It’s a very complicated kind of thing. But I’ve had to go back and look at how other surgeons operate to tailor how I do my operation.
Speaker 1 (46:39):
So that’s a, colors are unique. So any stoma they have to go through the abdominal wall. It’s usually not as big of a hole as a parastomal hernia, which involves usually small intestine or a colon but it can be big depending on where they got, where made their new bladder from their different techniques. And there’s one name, I forgot the name is kind of a cool name, starts the b I think that’s the one that’s gives you the most hernias, but Okay. The one thing I learned, which I’ll share with you is ileall conduits, because its small bowel, are very, very sensitive to Mesh. So I’ve had multiple patients that have had a typical parastomal hernia repair where the Mesh touches the ill conduit and it’s eroded into the conduit. So I do not do any Intraperitoneal Mesh. I stay away from the conduit, stay away from the ureters because you don’t want to mess up that reconstruction. And I do those as either on open Onlay or open retro muscular. And I stay away from the conduit as much as possible.
Speaker 2 (47:55):
I know that I don’t biologic around that area because biologic does not last. And then also keyhole keyhole does not work. I mean, I’ve done a number of just to get out of a jam to do a keyhole. Yeah, it’s really, but they tend not to work either. It is a developing, the good thing
Speaker 1 (48:13):
With Corona is you can’t obstruct the urine.
Speaker 2 (48:16):
True <laugh>,
Speaker 1 (48:17):
Hard to obstruct that you can make it too tight and it’s still okay, unlike a regular stoma where you’ll get a bowel obstruction.
Speaker 2 (48:26):
So that’s actually something I learned from you. And I still use in my clinic. This is a Goldilocks operation. You cannot make it too tight. You cannot make it too loose. And I’m very anal when I do this surgery because it has to be just right. So I deflate the abdomen, I blow it up, I make sure that U is flowing throughout the case. A nerve wracking surgery to do.
Speaker 1 (48:46):
Yeah, and like you said, you have to really conscious of where those ureters are. That’s that’s one operation you don’t want to mess up for the patient. All right. I think there’s one more question. Okay. How have you changed your surgical technique since working at MD Anderson?
Speaker 2 (49:09):
I really changed it all that much. It’s more of the surgical approach. I was talking about this with my physician assistant in clinic today. It’s more about when you do the appropriate surgery. That’s really what’s changed. I’ll say that the most important change that has happened since working at MD Anderson is the acquisition of robotic surgery. So yeah, I kind of hate to say it, but I feel like tars kind of a magic bullet. I feel like you can use it for almost everything, but it is one of the hardest procedures to learn. I spent all of 2017 learning to do that robotic and open at the same time because I didn’t get a lot of ab wall when I was a resident. So I kind of had to learn a lot of that. And so I guess my surgical technique has changed in this respect.
Speaker 2 (49:56):
I do a lot more intramuscular Mesh than I used to. I do a lot more component separation, in particular the posterior component separation. And then I had to pick up advanced robotic techniques such as the robotic eTEP Rives Stoppa that your Dr. Igor Belyansky does. That actually was a game changer for me because not everybody needs a tar, right? That’s a very big operation for sometimes these moderately sized hernias. And the only alternative I had around 2018 was just to split them open from xiphoid to pubic. But since I acquired that skill set that is now my second most popular robotic repair. So I do that a lot more than I did two years ago. So I guess the answer to this question is, my technique has changed more toward intramuscular width separation. I recently looked at my own outcomes because I was curious, alright, I have enough now I kind of want to know how I stacked up to other people.
Speaker 2 (50:53):
So my length of stay, because I’m a relatively conservative surgeon, I don’t like sending people home unless they’re passing gas and I’m old school like that. They have to pass gas and be able to eat. So my length of stay for these operations is about three days. In terms of their length of stay. When we were doing it open, it would be five to seven. So that’s a significant difference and also statistically significant. Additionally, I don’t fixate it anymore. I just glue the Mesh in and that has worked really well. So I haven’t had a lot of surgicals.
Speaker 1 (51:27):
You spray the glue?
Speaker 2 (51:29):
Yes.
Speaker 1 (51:29):
So Oh, drip it, spray
Speaker 2 (51:31):
It. I spray it. And I use about 20 ccs. So I use 20 on the top, 20 on the bottom and I’ll place a drain. So because I’ve eliminated fixation and trans fascial kind of closure, that has changed their pain regimens. And so they, I’m sending them home now on maybe 15 pills of tramadol and they maybe use five of those. So that actually helps with their bowel function and their recovery. So again, changing the technique changes, the pain changes. Their length of stay really has kind of revolutionized how I do thinks now as opposed to maybe six or seven years ago.
Speaker 1 (52:07):
Yeah, that’s true. Tell us how you’re doing in Texas. We have five minutes. I’d just like to get a little update of Texas. You mentioned that you are currently banned from, not you personally <laugh>, but you’re, your city is banning is it citywide or statewide? Elective surgery.
Speaker 2 (52:27):
So statewide. Yeah. So Dr not doctor. Governor Abbott has a state mandate where we don’t do elective surgery. It’s only surgery that is emergent because they have a risk of contracting COVID or has a risk of minimal risk of taking a lot of resources in the hospital for COVID patients. So an outpatient surgery. But things that I’m allowed to do right now. So vascular access for chemotherapy, hernias that have potential for incarceration or something that’s going to prevent them from getting their chemotherapeutic regimens because they have not it’s going to delay their therapy. So those are things that I can do.
Speaker 1 (53:11):
And you’re staying safe.
Speaker 2 (53:13):
Of course. Always.
Speaker 1 (53:19):
Yeah. I miss you. I feel like we haven’t had a lot of meetings to go to the past year. They all got switched to being online. Are you part of the American Hernia Society? I am company this
Speaker 2 (53:32):
Year. I recently got accepted. There’s a video little plug there that was going to present in New York. So it’s actually interesting. So it’s a robotic tap video. There’s tons of those. But this is from the perspective of someone who works at cancer center. So they’re just a little spoiler. There’s a Spigelian that happened after a tummy tuck. There is a defect in the abdominal wall that happened after a tram. And there is a super pubic that is on a bony providence from a super pubic catheter. So these are weird hernias that I was able to solve with a tap essentially.
Speaker 1 (54:06):
That’s awesome. We didn’t discuss the breast reconstruction surgery, but tram flaps, deep flaps, these are all different abdominal wall procedures that are done as part of that reconstruction of a breast, often for cancer. And that can cause some serious abdominal wall defects. That can be really tricky because you’re missing, well, in a tram flap, you’re missing the actual muscle and one layer of fascia and with a deep flap you can be injuring that fascia as part of the deep flap. So yeah, those can be tricky to repair.
Speaker 2 (54:47):
And they may or may not have a underlying biologic Mesh. So it’s a very, again, read about your patient, learn to read cts, really be diligent about how you take care of these patients.
Speaker 1 (54:59):
Yes, totally agree. Totally agree. Well I hope you stay safe. We were banned in Beverly Hills only, not Los Angeles City. Beverly Hills only from elective surgery for about a month. I think mostly because I’m surrounded by plastic surgeons in Beverly Hills and they didn’t want people coming in getting breasts, implants and Botox face facelifts during a pandemic. Interesting. But the parks and Beverly Hills, I was caught in that, which was fine right? Safety first. But to have the whole state shut down for elective surgery, that’s a big deal.
Speaker 2 (55:39):
It is. So that’s
Speaker 1 (55:40):
A lot of surgeries.
Speaker 2 (55:42):
Yes,
Speaker 1 (55:43):
And a lot of hernia surgeries.
Speaker 2 (55:45):
I’ll be honest though, I’ve been happy with, I feel safe working where I work because I feel like they really do take care of us. I haven’t felt unsafe in my work environment. I can’t say that for everybody, but I feel really blessed to be where I am at.
Speaker 1 (55:59):
Good for you. Good for you. I wish you were in California because then we could hang out some more <laugh>.
Speaker 2 (56:07):
I don’t want to get my nose kind of. Not with that. I’m like, I dunno if I want that.
Speaker 1 (56:13):
I know. So we had a meeting in Houston and Dr. Santos was awesome and he showed me his workplace, his office workplace at AMD Anderson, which is a fascinating, huge village. Basically filled with buildings. And I got to check out the different his office, but also the different kind of patient areas and the operating room areas. So as surgeons, we sometimes that’s like the sight seeing we do where we go to different hospitals to see how other hospitals are. And it was a wonderful place and I’m so proud of everything you’ve done since your fellowship. You’ve been great. And I like that you keep in touch and thank you for sharing your time with us.
Speaker 2 (57:00):
Very good. Well, thank you for having me. I totally appreciate it.
Speaker 1 (57:04):
Thank you. So on that note, I would like to just say thank you to Dr. Santos for his time and for all of you who have been joining us that we will have this broadcast on YouTube for you to share and rewatch and share with your friends. It is already on Facebook Live, and I will post the links of that on Twitter and Instagram. Thank you again, Dr. Santos, and next week, next Tuesday, we will have yet another amazing surgeon to talk with. And on that note, everyone have a great rest of your evening and I hope you all stay safe and thank you again. Bye David. Bye.
