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Outpatient Setting Very Safe for Skin Cancer Surgery

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Duke Health News 919-660-1306

Durham, N.C. -- Mohs micrographic surgery, a common technique used to remove skin cancers, is very safe when performed in an outpatient setting, according to a study published in the Feb. 17, 2003, issue of the Archives of Dermatology. The researchers said their results counter the arguments of legislators, lobbyists and others who question the overall safety of outpatient surgeries.

"It is concerning as a physician to see lobbyists and policy makers openly criticize medical practice without the benefit of data to support their arguments," said study lead author Jonathan Cook, M.D., director of dermatologic surgery at Duke University Medical Center.

The study, conducted by Cook and resident physician Jennifer Perone, M.D., assessed rates of complications associated with 1,343 outpatient Mohs procedures performed at Duke during 2000. The overall complication rate was 1.64 percent, or 22 complications out of the 1,343 surgeries. Thus, said the researchers, the complication rate is low enough to conclude that performing Mohs surgery on an outpatient basis does not represent an undue risk.

Mohs surgery, also known as microscopically controlled surgery, was developed by Frederic Mohs, M.D. for the treatment of certain skin cancers. Performed under local anesthesia, the technique combines surgical removal of the skin cancer with immediate microscopic examination of the removed tissue in order to identify any residual cancerous tissue. The surgeon continues the process of removing tissue and studying it under the microscope until all cancer has been removed. Typically, the surgeon then reconstructs the surgical wound by using a variety of repair techniques.

The Mohs technique has the highest cure rate of all skin cancer treatment methods, and involves the surgical removal of the least amount of tissue possible in order to adequately treat the cancer.

"Of course, any surgical procedure has to be performed in a supervised setting," said Cook, "but this study shows the rarity of complications that occur with Mohs surgery performed by an appropriately trained physician.

"We all see reports in the news of undesired patient outcomes following surgery," Cook continued. "Although dermatologic surgery is largely not responsible for these cases, people tend to generalize and assume that all outpatient surgery is dangerous."

The Duke team tracked each Mohs surgical procedure performed during 2000 and logged clinical observations regarding complications into a database. Complications were evaluated and treated by the physicians. In addition to general information about the area of the surgery and type and size of cancer removed, the researchers recorded information about the occurrence of the six types of complications most likely to follow Mohs surgery:

· Post-operative hemorrhage -- significant bleeding that required treatment by a physician in the post-operative period

· Hematoma -- painful swelling that indicated significant delayed bleeding at the operative site

· Wound dehiscence -- partial or complete separation of the wound edges after sutures had been placed

· Wound infection -- an infection of the surgical site

· Skin flap or skin graft necrosis -- partial tissue loss of skin used to reconstruct the surgical wound after the cancer had been removed

Of the 22 complications that occurred during the study period, the majority involved difficulties with excess bleeding. None of the patients required hospitalization or consultation with another physician.

The researchers note that outpatient settings may be not only more comfortable and accessible to patients than hospitals, but that they also may be a more cost-effective location for providing quality care for Mohs patients.

"In the overwhelming majority of patients, there really is no need for this type of surgery to be performed in an inpatient setting," said Cook.

"Dermatologists and dermatologic surgeons provide care for the majority of skin cancer patients in the United States," said Cook. "This study demonstrates the safety of performing Mohs surgery on an outpatient basis -- a valuable setting for providing efficient and cost-effective care for skin cancer patients."

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