Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Surgical Tutorial 1: Tissue Extraction
PROGRAM CHAIR
Sarah L. Cohen, MD, MPH
Bernd Bojahr, MD Steve Yu, MD
Professional Education Information Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Prevalence of Leiomyosarcoma among 10,731 Laparoscopic Supra‐Cervical Hysterectomies B. Bojahr ....................................................................................................................................................... 3 Uncontained Morcellation: Rationale and Technique S. Yu .............................................................................................................................................................. 6 Contained Morcellation S.L. Cohen ...................................................................................................................................................... 9
Cultural and Linguistics Competency ......................................................................................................... 14
Surgical Tutorial 1: Tissue Extraction
Sarah L. Cohen, Chair
Faculty: Bernd Bojahr, Steve Yu The recent controversy concerning the prevalence of leiomyosarcoma (LMS) among women having
surgery for presumed uterine fibroids has focused attention on the risks of tissue extraction in women
with undiagnosed LMS. Methods for both contained and uncontained morcellation have been
developed to reduce intra-peritoneal tumor spread, which might potentially change the patient's
prognosis. The prevalence of LMS, derived from a large study, will be presented, and both contained and
uncontained morcellation techniques will be illustrated with video.
Learning Objectives: At the conclusion of this course, the participant will be able to: 1) Discuss the
prevalence of leiomyosarcoma among women having surgery for presumed uterine fibroids; 2) describe
techniques for both contained and uncontained morcellation.
Course Outline
11:00 Welcome, Introductions and Course Overview S.L. Cohen
11:05 Prevalence of Leiomyosarcoma among 10,731 Laparoscopic Supra-Cervical Hysterectomies B. Bojahr
11:20 Uncontained Morcellation: Rationale and Technique S. Yu
11:35 Contained Morcellation S.L. Cohen
11:50 Questions & Answers All Faculty
12:00 Adjourn
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Bernd Bojahr* Sarah L. Cohen Consultant: Olympus Steve Yu* Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.
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Prevalence of Leiomyosarcoma among 10 731 Laparoscopic Supra‐
Cervical Hysterectomies
Prof. Bernd Bojahr
Klinik für MIC Minimally Invasive Center
Berlin, Germany
Prevalence of Leiomyosarcoma among 10 731 Laparoscopic Supra‐Cervical
Hysterectomies
Disclosures:
I have no financial relationships to disclose.
Prof. Bernd Bojahr
Prevalence of Leiomyosarcoma among 10 731 Laparoscopic Supra‐Cervical
Hysterectomies
Objective:
This study aims to evaluate the number of
cases of occult uterine malignancies in all
LASH surgeries at the MIC clinic (Berlin)
and to verify how the operative technique
affects the prognosis of the disease.
Especially the prevalence of
leiomyosarcomas and the results will be
analyzed and discussed.
Statements and Questions
• 600 000 hysterectomies each year (MIS 30% ‐2002 ‐ 63% ‐2012)
• 50 000 ‐150 000 annualy with morcellation
AAGL: Morcellation is contraindicated in presence of documented
or highly suspected malignancy !
(imperative: preoperative screening guidelines – including endometrialbiopsy and cervical cytology)
38‐68% of leiomyosarcomas can be detected in this manner
Data insufficient to discontinue power morcellation in appropriately
screened patients at low risk.
Leiomyosarcomas ‐ aggressive malignancy ! Outcomes are suboptimal with
and without morcellation !
„Decision Analysis Model“ was constructed based on available literature:
Converting all hysterectomies currently performed with morcellation
to abd. hysterectomy – would result in an increase of 17 more women dying
from surgery each year and a substantial morbidity from open surgery.
AAGL:
•Our obligation is not only to patients with
leiomyosarcoma but to all of our patients !
•We must not sacrifice the well‐being of
our patients in response to a rare event !
•We should improve but not abandon power morcellation
•Power morcellation with appropriate informed consent shouldremain available to appropriately screened women at low risk !
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•4864 articles identified – 60 in full evaluated
•Aim: May Morcellation of occult leiomyosarcomas substantially worsen patients outcome ?
•17 with outcome informations: 6 addressed the question of whether morcellation of leiomyosarcomas result in inferior outcomes as compared with en bloc removal.
•Results suggested that en bloc removal may result in improved survival and less recurrence – the data are highly biased and of poor quality.
•There is no evidence from these 17 studies that power morcellation differs in any way from other types of morcellation or even simple myomectomy insofar as patients outcome.
•More investigations are necessary before conclusions are drawn and policies created regarding the danger of morcellation of leiomyosarcomas for the patient.
Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH)
Bernd Bojahr, Rudy Leon De Wilde, Garri TchartchianArch Gynecol Obstet (2015) 292: 665‐672
indication patients %
uterine myoma 8720 81.3
bleeding disorder 1015 9.4
suspicion of
adenomyosis/pain
361 3.4
prolaps 635 5.9
n % + SD (range)
uterine malignancies 13 0.13 ± 3.6 (0.128 – 0.133)
sarcoma 6 0.06 ± 2.4 (0.054 - 0.057)
low grade endometrial stromal sarcoma 4 0.04
leiomyosarcoma 2 0.02 ± 1.4 (0.018-0.019)
endometrial cancer 7 0.07 ± 2.7 (0.073 – 0.076)
endometrial cancer in-situ 1 0.01
adenocarcinoma located in a polyp 1 0.01
undifferentiated endometrial carcinoma 1 0.01
endometroid adenocarcinoma 5 0.05
Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH)
Bernd Bojahr, Rudy Leon De Wilde, Garri TchartchianArch Gynecol Obstet (2015) 292: 665‐672
Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH)
Bernd Bojahr, Rudy Leon De Wilde, Garri TchartchianArch Gynecol Obstet (2015) 292: 665‐672
endometrial
cancer sarcoma all uterine
malignomas
Patients age
mean years + SD 51.4 ± 6.1 48.7 ± 5.7 50.2 ± 5.8
range 51.6 - 53.2 48.5 - 49.9 50.1 - 51.1
Patients height
mean cm + SD 171.4 ± 7.0 168.8 ± 3.5 170.4 ± 5.7
range 171.3 - 175.3 168.7 - 173.1 170.3 - 173.2
Patients weight
mean g + SD 88.9 ± 31.6 75.2 ± 12.9 83.0 ± 25.6
range 88.2 - 90.8 74.8 - 77.1 82.6 - 84.4
Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH)
Bernd Bojahr, Rudy Leon De Wilde, Garri TchartchianArch Gynecol Obstet (2015) 292: 665‐672
Sarcomas – Follow up surgery after 51 days (2‐91) after LASH –All patients without residual tumor or metastases
1 patient (Leiomyosarkoma, Uterus 1000gm) 2 month after LASH removal of cervix – no signs of recurrence/metastases; 10 Months after LASH peritoneal carcinomatosis and bone metastases and died after 13 months.
•Follow up: 6/6 patients with sarcomas and 7/8 with endometrial cancer(no follow up informations of the patient endometrial Ca in situ)
•Follow up 65,6 months (13‐169)•All patients with Follow up informations had follow up surgery
Endometrial cancers – no recurrences during follow up surgery within 32 days (11‐56) with a Follow up of 74 months (16‐169)
1 patient with a undifferentiated endometrial cancer and 5 positive lymph nodes ‐ 61 months without signs of recurrences
• The youngest patient with a sarcoma was 43 years old.• Till today we did not find a sarcoma during myomectomies.• 2014: 1499 operations (LASH,LAVH, Myomectomies,
Hysteroscopic Myomresections) – no sarcomas and no atypical myomas !
Aim for the future:
‐Improvement of Morcellation Technique
‐ Evaluation of all cases after morcellation of sarcomas
(Follow up)
‐ Register for all sarcomas (national/international ?)
‐Bag Techniques should be investigated for safety and outcomes.
ESGE, AGE, DGGG,ACOG, AAGL, AUGS, SGO, SGS:
Support the further use of morcellation for patients with appropriate informed consent and low risk.
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• Recommendation:
‐ Abundant lavage at the end of laparoscopy
‐ Removal of all abdominal remnants of myomas and tissues
‐ Careful control of the area of operation (incl. middle and upper abdomen)
Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH)
Bernd Bojahr, Rudy Leon De Wilde, Garri TchartchianArch Gynecol Obstet (2015) 292: 665‐672
Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH)
Bernd Bojahr, Rudy Leon De Wilde, Garri TchartchianArch Gynecol Obstet (2015) 292: 665‐672
•Conclusions
All patients should be informed about the
very low incidence of sarcomas during
preoperative counceling.
(FDA 1/350) own datas 1/1788 ‐ 0,06% !
With a timely follow up surgery according to
the oncologic guidelines our datas suggest a
very good prognosis in terms of survival after LASH with morcellation of malignant tumors in the uterus.
Thank you for your attention!
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Uncontained Morcellation: Rationale and Technique
Steve Yu, MDAssistant Clinical Professor
Department of Obstetrics and Gynecology
David Geffen School of Medicine
University of California, Los Angeles
I have no financial relationships to disclose.
Objectives
• Explain the rationale for uncontained morcellation.
• Demonstrate the techniques of controlled tissue extraction.
Rationale
• Cells are aerosolized during hysterotomy.
• Blood from the myoma/sarcoma spills into the peritoneal cavity during dissection & repair.
• Morcellation in a bag increases O.R. time.
• Morcellation in a bag has its inherent complications.
Dissemination of Cells Dissemination of Cells
6
20
6
3 samples positivePre‐morcellation &Post‐morcellation
3 samples positivePost‐morcellation
Sample size:
Positive washing:
Sample size: 5
Washing prior myomectomy
0 positive
Washing after myomectomy
3 positive
Technique
• Controlled morcellation
• Extract all visible myoma fragments.
• Copious irrigation
Controlled Morcellation
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Copious Irrigation References
Toubia, Tarek, et al., Peritoneal Washings After Power Morcellation in Laparoscopic Myomectomy: A Pilot Study. Journal of Minimally Invasive Gynecology (2016) 23, 578-581.
Sandberg, EM, et al., Disseminated leiomyoma cells can be identified following conventional myomectomy. BJOG (2016); DOI: 10.1111/1471-0528.14265
Structured Video Abstract:Uncontained Morcellation: Rationale and Technique
Steve Yu, M.D.University of California, Los Angeles
Objective: To explain the rationale for uncontained morcellation and to demonstrate controlled tissue extraction.
Design: Display of myoma cell dissemination during laparoscopic myomectomy prior to morcellation and demonstration of tissue extraction with narrated video footage.
Setting: Advances in minimally invasive surgery (MIS) have significantly improved surgical care in women’s health. In order to remove any tissue considerably larger than the diameter of the secondary trocar requires morcellation. In recent years, there has been considerable scrutiny in power morcellation due to the risk of morcellating an unsuspected uterine leiomyosarcoma, with the potential to disseminate cancer cells. To mitigate this risk, many MIS surgeons have demonstrated techniques to morcellate in a contained bag. However, this is practice has not been shown to prevent dissemination of cells, and it has its inherent complications. Further, due to the technical steps necessary to enucleate a myoma, dissemination of myoma cells occurs prior to morcellation.
Intervention: Minimize the risk of myoma cell dissemination during laparoscopic myomectomy by:
1. Controlled morcellation2. Meticulously removing all visible myoma fragments3. Copious irrigation
Conclusion: Historically, large tissue extraction required a laparotomy, which is associated with more pain, longer hospitalization, increased risk of hemorrhage and increased risk of infection. Power morcellation has significantly advanced MIS in women’s health care. Minimizing the risk of myoma/sarcoma cell dissemination requires improved techniques in tissue extraction outlined previously.
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Surgical Tutorial: Tissue ExtractionContained Morcellation
Sarah L. Cohen, MD MPH
Director of Research
Division of Minimally Invasive Gynecologic Surgery
Brigham and Women’s Hospital
PHS IS2
Disclosures
Consultant: Olympus
Objectives Review options, tips and tricks for contained
morcellation Power
Vaginal
Minilaparotomy
From innovation to possible solution
KA ‘Tony’ Shibley MD Video at AAGL in 2012 detailing tissue isolation
and extraction within artificial pnemoperitoneum
Initially developed for use with single-site laparoscopic supracervical hysterectomy
Single port Shibley VideoContained Power Morcellation
Initial Technique: Cohen et al. Obstet Gynecol. 2014. Collaboration between BWH, MGH, JHH, KA Shibley
Many follow-up studies demonstrating variations on technique, equipment
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Slide 1
PHS IS2 I don't know what the politics are of name ordering! I figured I should be near the end, but the very end seems to be for VIPs... I leave it to youPartners Information Systems, 8/27/2015
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Contained Power Morcellation: Multi-port approach Video
Contained Power Morcellation: How long does it take? Vargas et al. JMIG. 2015
Compared OR time 3 months before and after implementing in bag power morcellation
36 IBM, 49 open morcellation; IBM added 26 minutes to OR time
Winner et al. Obstet Gynecol. 2015
101 uncontained morcellations, 51 contained between 2012-2015
20 minute increase in OR time
Contained Power Morcellation: Is it safe?
Cohen et al. AJOG 2015. Prospective study across 7 sites in Boston
Multi-port approach, varying bags used
Primary outcome: leakage of tissue or blue dye
Enrollment goal 400, early stop at 89 patients due to leakage events
7 cases of dye or tissue leakage on post morcellation survey
Surgical equipment catches up Paul et al. JMIG 2015.
MorSafe Bag, designed with sleeve
Rimbach et al. Arch Gynecol Obstet. 2015
Optic trocar access with sleeve to protect camera
Pig model of 8 cases of LSH
12 mins added OR time
Negative peritoneal cytology washings
FDA approved containment bag Pneumoliner – images and video
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What if I don’t have a power morcellator, or don’t want to use one?
Useful for total hysterectomy cases
Most efficient with parous patients, adequate pelvic outlet or smaller pathology
Vaginal specimen removal:
Contained Vaginal Morcellation
•Insert containment bag of choice •Based on specimen size, use abdominal wall incision (12-15mm) or colpotomy site•Place specimen into bag with cervix directed to opening of bag
Contained Vaginal Morcellation
Exteriorize bag at introitus
May utilize self retaining retractor to facilitate unhindered exposure
Rocking motion during manual morcellation with scalpel
Contained Vaginal Morcellation Video
What if I don’t have a power morcellator, or don’t want to use one?
Useful for myomectomy, supracervical hysterectomy
Large specimens (>16-18 wks)
Minilaparotomy:
Contained Minilaparotomy Morcellation
Umbilicus or suprapubic, 2.5-5cm
Tips to extend port at umbilicus
Insert containment bag of choice
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Single port device helpful to allow for return to LSC view
Place specimen in bag, exteriorize bag at abdominal wall
11 blade scalpel, morcellate in strips allowing specimen to roll
Contained Minilaparotomy Morcellation Minilaparotomy Technique
Contained Minilaparotomy Morcellation Useful Products GelPOINT mini (Applied Medical) – single port device useful for minilap morcellation
Alexis Contained Extraction System (Applied Medical) – bag with stiff rim, 17cm diameter, 6500mL capacity
Alexis Wound Retractors (Applied Medical) – varying sizes, useful to keep bag orifice open
LapSac (Cook Medical)- 8x10cm, 1500mL capacity, comes with optional introducer
EndoCatch (Covidien)- 15mm device with introducer and bag has 12..7cm diameter, 1000mL capacity
EcoSac Specimen Retrieval Bags (Espiner) – varying sizes, capacity upwards of 2000mL
180 bag is 17x24cm
Lahey/Containment bag (3M) – thin material, accommodates very large specimens, 50x50cm
In Summary
Many tissue removal options exist
Contained extraction via vagina, minilaparotomy or with power morcellation
Much of the equipment we are currently using for contained morcellation was not created for this purpose
Further study, technique refinement and work with industry required for continued improvement
U.S. Food and Drug Administration. UPDATED Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA SafetyCommunication. November 14, 2014.
Park JY, Park SK, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. The impact of tumor morcellation during surgery on the prognosis ofpatients with apparently early uterine leiomyosarcoma. Gynecol Oncol. 2011; 122(2):255-9.
Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben-Baruch G. Uterine leiomyosarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer. 2009;19(2):257-60.
George S, Barysauskas C, Serrano C, Oduyebo T, Rauh-Hain JA, Del Carmen MG, Demetri GD, Muto MG. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer. 2014;120(20):3154-8.
Einarsson, JI, Cohen SL, Fuchs-Weizman N, Wang KC. In bag morcellation. J Minim Invasive Gynecol. 2014; 21(5):951-3.
Cohen SL, Einarsson JI, Wang KC, Brown DN, Boruta D, Scheib SA, Fader AN, Shibley KA. Contained power morcellation within an insufflated isolation bag. Obstet Gynecol. 2014; 124(3):491-7.
Cohen SL, Greenberg JA, Wang KC, Srouji SS, Gargiulo AR, Pozner CN, Hoover N, Einarsson JI. Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol. 2014; 21(5):935-9.
Vargas MV, Cohen SL, Fuchs-Weizman N, Wang KC, Manoucheri E, Vitonis AF, Einarsson JI. Open power morcellation versus contained power morcellation within an insufflated isolation bag: comparison of perioperative outcomes. J Minim Invasive Gynecol. 2015 ;22(3):433-8.
Winner B, Porter A, Velloze S, Biest S. Uncontained Compared With Contained Power Morcellation in Total Laparoscopic Hysterectomy. Obstet Gynecol. 2015; 126(4):834-8.
Cohen SL, Morris SN, Brown DN, Greenberg JA, Walsh BW, Gargiulo AR, Isaacson KB, Wright K, Srouji SS, Anchan RM, Vogell AB, Einarsson JI. Contained Tissue Extraction using Power Morcellation: Prospective Evaluation of Leakage Parameters. Am J Obstet Gynecol. 2015; in press.
Akdemir A, Taylan E, Zeybek B, Ergenoglu AM, Sendag F. Innovative technique for enclosed morcellation using a surgical glove. Obstet Gynecol. 2015 ;125(5):1145-9.
Paul PG, Thomas M, Das T, Patil S, Garg R. Contained morcellation for laparoscopic myomectomy within a specially designed bag. J Minim Invasive Gynecol. 2015. pii: S1553-4650(15)00611-1
Rimbach S, Holzknecht A, Nemes C, Offner F, Craina M. A new in-bag system to reduce the risk of tissue morcellation: development and experimental evaluation during laparoscopic hysterectomy. Arch Gynecol Obstet. 2015 Dec;292(6):1311-20.
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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsian
Indo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
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