Cutting Concerns – Baystate’s Chair of Surgery Ponders a Rapidly Evolving Field

Dr. Nicolas Jabbour left Belgium in 1987 for what he thought woukd be a short stint in the Big Apple.

“I left to do one year in New York, but ended up staying 26 years,” he told HCN. “The obvious reason is, it’s the most advanced healthcare system in the world. Most people outside this country seek U.S. healthcare if they need it.”

Internationally recognized as a liver-transplant surgeon, Jabbour — who spent time at UMass Medical School, the University of Southern California, and the University of Pittsburgh during his quarter-century stay in the U.S., did return a few years ago to Catholic University of Louvain in Brussels, but last year returned to the States when he accepted the chair of the Department of Surgery at Baystate Medical Center.

The differences between U.S. and European healthcare aren’t as wide as one might think, he told HCN — mainly matters of insurance and access; regarding the latter, for example, American patients don’t have to wait months to get a hernia fixed or a gallbladder taken out.

In addition, “coming from Europe, the transparency and quality of the data we get from the U.S. healthcare system is probably unmatched in any industrialized country,” said Jabbour, who is also a professor and chair of the Department of Surgery at UMass Medical School – Baystate, set to open in Springfield this fall.

But when it comes to the high-tech elements of surgery, they’re equally impressive on either side of the pond, although a less-regulated climate often fosters more innovation overseas.

That’s not to say Baystate isn’t innovating. For example, the hospital’s Trauma division has developed a rib-fixation program that shortens length of stay and time on the ventilator in thoracic trauma patients. A large achalasia program offers purely endoscopic surgery to treat that gastroenterological disease; Baystate doctors learned the procedure, known as POEM, in Japan in 2011 and boast the most experience at it in New England. In addition, Baystate pediatric surgeons are advancing single-incision laparoscopic surgery, which was recognized by New England Surgical as a clinical award winner.

Meanwhile, the hospital’s breast surgeons continue to perfect breast-cancer localization surgery with radioactive seed implantation, with more than 900 seeds planted since 2010. And Baystate’s robotic-surgery program, introduced in 2005, continues to grow, with providers in bariatric, colorectal, oncologic, thoracic, and urologic surgery performing almost 4,000 procedures through 2016, with 546 cases last year alone.

Jabbour recalled the introduction of advanced laparoscopy in the U.S. in 1990 and compared the excitement over that tool with what’s available today. “It was such an innovation, but it was a bit rudimentary compared to the new laparoscopic instruments, which are much more advanced. And we’ve moved to robotic surgery, which allows us to see things in a tri-dimensional way. It’s a much better approach to certain cases where we’re limited by visibility and the articulation of the instrument. It’s had a positive impact.

“These are very advanced tools we have available in this area; we’re lucky to have access to this technology,” he said, but he was also quick to credit less-flashy advances, such as the cross-disciplinary approach — involving specialists from surgery and gastroenterology — demonstrated on the POEM procedure, or the way the new rib-fixation technique makes recovery an easier process for patients. “That’s not sexy like robotics, but it’s important for a specific type of patient. When we talk about innovation, we have to think about the impact on patients.”

Practice Makes Perfect

Speaking of patient impacts, Baystate’s growing range of surgical-simulation technology allows students to practice their skills without fear of harming an actual person.

“Simulation centers are a great innovation,” Jabbour said. “I always wonder why we have to learn operating-room skills on patients — how to dissect, how to suture things together. Right now, we’re training six or seven surgeons per year, and we’re one of the limited number of simulation centers for surgical training in the country. This simulation center provides us with the tools to educate residents outside of the patient. We’re making training safer and better. When the resident is in the operating room, he’s already better-prepared to perform surgery. It’s the same way for pilots: you don’t have to be in a plane to learn how to fly a plane.”

As for the future, Jabbour would like to expand NOTES technology at Baystate, a surgical technique that uses the body’s natural orifices — for example, fixing a hernia by running instruments into the mouth and down through the stomach.

“Why do we do innovation in general? It’s to make surgery safer or better, but also in response to what the public wants,” he said. “That’s what drives innovation — a desire for surgery that’s less scary, with earlier recovery, shorter hospital stay, fewer complications. NOTES might sound futuristic, but 10 years from now, it won’t seem futuristic at all.”

Considering how deeply a culture of patient safety has seeped into all areas of the hospital (see story, page 14), it wasn’t surprising that Jabbour brought up that topic as well. In fact, safety is one of four values — the other three are quality, patient experience, and cost — that Baystate aims to apply to every department. And while no procedure is ever 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} safe, he said surgery has become safer through a very low-tech concept: communication.

“Our culture here makes sure everyone in the operating room can speak up; if something doesn’t feel right or is out of the ordinary, it’s safe to speak,” he said. “I’m not old, but in my time, you could not speak up; the surgeon was the dictator of the operating room. Now, everyone on the team is important, from the person who cleans the operating room to the nurses and anesthesiologists and scrub techs. Everyone is part of a team providing the best care for the patient, so they have to feel safe speaking up. If they see something, people will thank them. That’s the sort of culture of safety I’m very keen on upholding.”

So, the surgeons at Baystate continue their work, honing what they’ve done dozens, if not hundreds, of times, while embracing new innovations — many of which, as Jabbour noted, originate in Europe, where the red tape required to develop new tools isn’t as strict.

“There has to be a balance between regulation and innovation, but you don’t want to choke innovation, either,” he told HCN. “That’s where politics and medicine intersect to some extent. “You have to uphold safety for the patient, but you also have to be careful not to prevent or delay innovation.”

It will be intriguing, to say the least, what high-tech surgical advances the next 10 years will bring to the modern hospital.