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Babic B, Mueller DT, Krones TL, Schiffmann LM, Straatman J, Eckhoff JA, Brunner S, Datta RR, Schmidt T, Schröder W, Bruns CJ, Fuchs HF. A senior surgical resident can safely perform complex esophageal cancer surgery after surgical mentoring program-experience of a European high-volume center. Dis Esophagus 2024; 37:doae015. [PMID: 38458619 DOI: 10.1093/dote/doae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/16/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Previous studies have shown that surgical residents can safely perform a variation of complex abdominal surgeries when provided with adequate training, proper case selection, and appropriate supervision. Their outcomes are equivalent when compared to experienced board-certified surgeons. Our previously published training curriculum for robotic assisted minimally invasive esophagectomy already demonstrated a possible reduction in time to reach proficiency. However, esophagectomy is a technically challenging procedure and comes with high morbidity rates of up to 60%, making it difficult to provide opportunities to train surgical residents. We aimed to investigate if a surgical resident could safely perform complex esophageal surgery when a structured modular teaching curriculum is applied. A structured teaching program based on our previously published modular step-up approach was applied by two experienced board-certified esophageal surgeons. Our IRB-approved (Institutional Review Board) database was searched to identify all Ivor-Lewis esophagectomies performed by the selected surgical resident from August 2019 to July 2021. The cumulative sum method was used to analyze the learning curve of the surgical resident. Outcomes of patients operated by the resident were then compared to our overall cohort of open, hybrid, and robotic Ivor-Lewis esophagectomies from May 2016 to May 2020. The total cohort included 567 patients, of which 65 were operated by the surgical resident and 502 patients were operated by experienced esophageal cancer surgeons as the control group. For baseline characteristics, a significant difference for BMI (Body mass index) was observed, which was lower in the resident's group (25.5 kg/m2 vs. 26.8 kg/m2 (P = 0.046). A significant difference of American Society of Anesthesiologists- and Eastern Cooperative Oncology Group-scores was seen, and a subgroup analysis including all patients with American Society of Anesthesiologists I and Eastern Cooperative Oncology Group 0 was performed revealing no significant differences. Postoperative complications did not differ between groups. The anastomotic leak rate was 13.8% in the resident's cohort and 12% in the control cohort (P = 0.660). Major complications (Clavien-Dindo ≥ IIIb) occurred in 16.9% of patients in both groups. Oncological outcome, defined by harvested lymph nodes (35 vs. 32.33, P = 0.096), proportion of lymph node compliant performed operations (86.2% vs. 88.4%, P = 0.590), and R0-resection rate (96.9% vs. 96%, P = 0.766), was not compromised when esophagectomies were performed by the resident. The resident completed the learning curves after 39 cases for the total operating time, 38 cases for the thoracic operating time, 26 cases for the number of harvested lymph nodes, 29 cases for anastomotic leak rate, and finally 58 cases for the comprehensive complication index. For postoperative complications, no significant difference was seen between patients operated in the resident group versus the control group, with a third of patients being discharged with a textbook outcome in both cohorts. Furthermore, no difference in oncological quality of the resection was found, emphasizing safety and feasibility of our training program. A structured modular step-up for training a surgical resident to perform complex esophageal cancer surgery can successfully maintain patient safety and outcomes.
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Affiliation(s)
- Benjamin Babic
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
- Center for Esophagogastric Cancer Surgery, St. Elisabethen Hospital Frankfurt, Frankfurt, Germany
| | - Dolores T Mueller
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Tillman L Krones
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Lars M Schiffmann
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Jennifer Straatman
- Department for Upper GI Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Jennifer A Eckhoff
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Stefanie Brunner
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Rabi R Datta
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Wolfgang Schröder
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Hans F Fuchs
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
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Jeon D, Chung Y, Paik B, Kim YJ. Laparoscopic Sleeve Gastrectomy plus Duodenojejunal Bypass: Learning Curve Analysis and Technical Feasibility of Duodenojejunostomy Using Linear Stapler. Obes Surg 2024; 34:22-29. [PMID: 37985570 DOI: 10.1007/s11695-023-06940-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/25/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy plus duodenojejunal bypass (LSG-DJB) has emerged as an alternative bypass surgery. Despite its potential benefits, the technical challenges of the procedure have limited its adoption. This study aims to present the learning curve for LSG-DJB and explore potentially beneficial technical modifications for the standardization of the procedure. METHODS The study retrospectively analyzed 100 patients who underwent LSG-DJB as a primary procedure from July 2014 through September 2021. Baseline characteristics, weight loss outcomes, remission of metabolic diseases, and perioperative complications were assessed. The operative time was analyzed across both time trends and anastomosis type subgroups. RESULTS At 1-year follow-up after LSG-DJB, the mean %total weight loss and the mean BMI loss were 25.38 ± 8.58% and 9.38 ± 4.25 kg/m2, respectively. Remission rates for type 2 diabetes, hypertension, and dyslipidemia were 72.0% (67/93), 84.1% (37/44), and 70.3% (52/74), respectively. In the analysis of operative time, the learning curve exhibited a plateau after 25 cases. The mean operative time was 136.00 ± 21.64 min in the stapled anastomosis group, and 150.62 ± 25.42 min in the hand-sewn anastomosis group. CONCLUSION The learning curve for LSG-DJB plateaued after 25 cases. In the LSG-DJB procedure, stapled duodenojejunal anastomosis is feasible and achieves similar outcomes to the hand-sewn method.
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Affiliation(s)
- Dongjae Jeon
- Department of Surgery, H+ Yangji Hospital, Seoul, Republic of Korea
| | - Yoona Chung
- Department of Surgery, H+ Yangji Hospital, Seoul, Republic of Korea
| | - Bomina Paik
- Department of Surgery, H+ Yangji Hospital, Seoul, Republic of Korea
| | - Yong Jin Kim
- Department of Surgery, H+ Yangji Hospital, Seoul, Republic of Korea.
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Zimmerman A, Bhimani N, Chan P, Mitchell D, Leibman S, Smith G. Initial experience with laparoscopic gastric bypass in an Australian general foregut surgery unit. ANZ J Surg 2023; 93:2857-2863. [PMID: 37658592 DOI: 10.1111/ans.18673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/31/2023] [Accepted: 08/12/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Laparoscopic gastric bypass (LGB) is an increasingly utilized approach to bariatric surgery in Australia. A high proportion of those procedures are revisional due to Australia's legacy of laparoscopic adjustable gastric banding (LAGB), which is not the case internationally. The aim of this study was to compare post-operative outcomes in an Australian general foregut surgery unit against benchmarks published in the literature. METHODS This is retrospective cohort study of morbidly obese patients undergoing primary or revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic one anastomosis gastric bypass (OAGB) with the two senior authors between 5 May 2015 and 27 June 2019. Perioperative data for the unit's first 100 cases were collected prospectively, stored on a unit database and analysed. Post-operative complications at 30 days, 90 days, mortality, length of hospital stay, and Defined Adverse Events were chosen as indicators of the perioperative outcome (as defined in the Monash Bariatric Surgery Registry). RESULTS In this cohort, 35% of procedures were RYGB and 65% were OAGB. The majority (58%) were revisional procedures. Most patients (74%) were female. The median age was 50. The comorbidity profile of the population was similar to those published internationally. The median hospital stay was 4 days. There was no mortality. Early complications occurred in 9% of patients, with 3% occurring late. CONCLUSION Outcomes of our first 100 cases are comparable with those recorded in the literature, notwithstanding a much higher proportion of revisional cases. LGB can be safely introduced in Australian general foregut surgery units by experienced laparoscopic surgeons.
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Affiliation(s)
- Andrew Zimmerman
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Nazim Bhimani
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Health and Medicine, University of Sydney, New South Wales, Australia
| | - Priscilla Chan
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Cancer Research Division, Cancer Council New South Wales, New South Wales, Australia
| | - David Mitchell
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Steven Leibman
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Garett Smith
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, University of Sydney, New South Wales, Australia
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Duran Espinoza V, Belmar Riveros F, Jarry Trujillo C, Gaete Dañobeitia MI, Montero Jaras I, Miguieles Schilling M, Valencia Coronel B, Escalona G, Tirado PA, Quezada N, Crovari F, Cohen JV. Five-Year Experience Training Surgeons with a Laparoscopic Simulation Training Program for Bariatric Surgery: a Quasi-experimental Design. Obes Surg 2023:10.1007/s11695-023-06616-0. [PMID: 37118641 DOI: 10.1007/s11695-023-06616-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE Nearly 200,000 laparoscopic Roux-en-Y gastric bypass (LRYGB) are performed yearly. Reported learning curves range between 50 and 150, even 500 cases to decrease the operative risk. Simulation programs could accelerate this learning curve safely; however, trainings for LRYGB are scarce. This study aims to describe and share our 5-year experience of a simulated program designed to achieve proficiency in LRYGB technical skills. MATERIALS AND METHODS A quasi-experimental design was used. All recruited participants were previously trained with basic and advanced laparoscopic simulation curriculum completing over 50 h of practical training. Ex vivo animal models were used to practice manual and stapled gastrojejunostomy (GJ) and stapled jejunojejunostomy (JJO) in 10, 3, and 4 sessions, respectively. The main outcome was to assess the manual GJ skill acquisition. Pre- and post-training assessments using a Global Rating Scale (GRS; max 25 pts), Specific Rating Scale (SRS; max 20 pts), performance time, permeability, and leakage rates were analyzed. For the stapled GJ and JJO, execution time was registered. Data analysis was performed using parametric tests. RESULTS In 5 years, 68 trainees completed the program. For the manual GJ's pre- vs post-training assessment, GRS and SRS scores increased significantly (from 17 to 24 and from 13 to 19 points respectively, p-value < 0.001). Permeability rate increased while leakage rate and procedural time decreased significantly. CONCLUSION This simulated training program showed effectiveness in improving laparoscopic skills for manual GJ and JJO in a simulated scenario. This new training program could optimize the clinical learning curve. Further studies are needed to assess the transfer of skills to the operating room.
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Affiliation(s)
- Valentina Duran Espinoza
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 377, 8330024, Santiago, Región Metropolitana, Chile
| | - Francisca Belmar Riveros
- Surgery Resident, Universidad de Chile, Av. Independencia 1027 Independencia, Santiago, Región Metropolitana, 8380453, Chile
| | - Cristian Jarry Trujillo
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 377, 8330024, Santiago, Región Metropolitana, Chile
| | - Maria Ines Gaete Dañobeitia
- Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Av. Libertador Bernardo O'Higgins 340, 8331150, Santiago, Región Metropolitana, Chile
| | - Isabella Montero Jaras
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 377, 8330024, Santiago, Región Metropolitana, Chile
| | - Mariana Miguieles Schilling
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 377, 8330024, Santiago, Región Metropolitana, Chile
| | - Brandon Valencia Coronel
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 377, 8330024, Santiago, Región Metropolitana, Chile
| | - Gabriel Escalona
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 377, 8330024, Santiago, Región Metropolitana, Chile
| | - Pablo Achurra Tirado
- Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Av. Libertador Bernardo O'Higgins 340, 8331150, Santiago, Región Metropolitana, Chile
| | - Nicolas Quezada
- Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Av. Libertador Bernardo O'Higgins 340, 8331150, Santiago, Región Metropolitana, Chile
| | - Fernando Crovari
- Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Av. Libertador Bernardo O'Higgins 340, 8331150, Santiago, Región Metropolitana, Chile
| | - Julian Varas Cohen
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 377, 8330024, Santiago, Región Metropolitana, Chile.
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Defining operative experience targets in surgical training: A systematic review. Surgery 2022; 172:1364-1372. [PMID: 36038374 DOI: 10.1016/j.surg.2022.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/07/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The surgical learning curve is an observable and measurable phenomenon. Operative experience targets are well established as a proxy measure for operative competence in surgical training across jurisdictions. The aim of this study was to critique the available evidence regarding the relationship between operative experience in surgical training and trainee competence. METHODS A systematic review of the PubMed, Embase, Web of Science, and Cochrane library databases was conducted in accordance with the Preferred Items for Systematic Reviews and Meta-Analyses guidelines. Articles were sought that defined the relationship between procedural volume in surgical training and trainee competence, proficiency, or mastery. The educational impact of included studies was evaluated using a modified Kirkpatrick model. RESULTS Of 3,672 records identified on database searching, 30 papers were ultimately included. Fourteen studies defined operative experience thresholds using operative time as a surrogate measure of competence, whereas another 8 used trainer assessments of operative performance (Kirkpatrick level 3). A further 5 studies were able to determine the relationship between trainee case volumes and subsequent patient outcomes (Kirkpatrick level 4b). CONCLUSION Many studies have recorded competent trainee performance in key index procedures after reaching experience threshold numbers in excess of currently mandated targets across jurisdictions. The evidence relating current operative experience targets to patient outcomes across a range of surgical subspecialties of surgical subspecialties is lacking. This review supports a move toward criterion-based referencing of operative performance targets in surgical training.
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Residents versus minimally invasive surgery fellows as first assistant: Outcome differences for laparoscopic Roux-en-Y gastric bypass. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Stenberg E, Dos Reis Falcão LF, O'Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg 2022; 46:729-751. [PMID: 34984504 PMCID: PMC8885505 DOI: 10.1007/s00268-021-06394-9] [Citation(s) in RCA: 133] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 02/08/2023]
Abstract
Background This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol. Methods A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations. Results The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries. Conclusion A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
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Affiliation(s)
- Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Mary O'Kane
- Dietetic Department, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Ronald Liem
- Department of Surgery, Groene Hart Hospital, Gouda, Netherlands.,Dutch Obesity Clinic, The Hague, Netherlands
| | - Dimitri J Pournaras
- Department of Upper GI and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, UK
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anupama Wadhwa
- Department of Anesthesiology, Outcomes Research Institute, Cleveland Clinic, University of Texas Southwestern, Dallas, USA
| | - Ulf O Gustafsson
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
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Vitiello A, Berardi G, Velotti N, Schiavone V, Musella M. Learning curve and global benchmark values of laparoscopic sleeve gastrectomy: results of first 100 cases of a newly trained surgeon in an Italian center of excellence. Updates Surg 2021; 73:1891-1898. [PMID: 34189700 PMCID: PMC8500908 DOI: 10.1007/s13304-021-01121-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/20/2021] [Indexed: 12/12/2022]
Abstract
To evaluate whether the learning curve for sleeve gastrectomy could be completed after 50 cases. First 100 patients undergoing LSG under a newly trained laparoscopic surgeon were included in this study and divided into two groups of 50 consecutive patients each. Perioperative outcomes were compared to recently introduced global benchmarks. Short-term weight loss was calculated as Total Weight Loss Percent (%TWL) and complications were classified in accordance with the Clavien–Dindo classification. CUSUM analysis was performed for operative time and hospital stay. Mean preoperative age and BMI were 41.8 ± 10.3 years and 42.9 ± 5.4 kg/m2, respectively. Demographics and rate of patients with previous surgery were comparable preoperatively in the two groups. Mean operative time was 92.1 ± 19.3 min and hospital stay was 3.4 ± 0.6 days as per our standard protocol of discharge. Uneventful postoperative course was recorded in 93% of patients and only one case of staple line leak was registered in the first 50 cases (group 1). No statistical difference in BMI and %TWL was found between the two groups at any time of follow-up. Comparison between two groups showed a significant reduction in hospital stay and operative time after the first 50 LSGs (p < 0.05). LSG can be performed by newly trained surgeons proctored by senior tutors. At least 50 cases are needed to meet global benchmark cut-offs and few more cases may be required to reach the plateau of the learning curve.
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Affiliation(s)
- Antonio Vitiello
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II", Via S. Pansini 5, 80131, Naples, Italy.
| | - Giovanna Berardi
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Nunzio Velotti
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Vincenzo Schiavone
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Mario Musella
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II", Via S. Pansini 5, 80131, Naples, Italy
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Wehrtmann FS, de la Garza JR, Kowalewski KF, Schmidt MW, Müller K, Tapking C, Probst P, Diener MK, Fischer L, Müller-Stich BP, Nickel F. Learning Curves of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Bariatric Surgery: a Systematic Review and Introduction of a Standardization. Obes Surg 2021; 30:640-656. [PMID: 31664653 DOI: 10.1007/s11695-019-04230-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG. METHODS A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected. RESULTS A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery. CONCLUSIONS Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.
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Affiliation(s)
- F S Wehrtmann
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - J R de la Garza
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - K F Kowalewski
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M W Schmidt
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - K Müller
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - C Tapking
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - P Probst
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - M K Diener
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - L Fischer
- Department of Surgery, Hospital Mittelbaden, Balger Strasse 50, 76532, Baden-Baden, Germany
| | - B P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - F Nickel
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Zerrweck C, Rodríguez NR, Sánchez H, Zurita LC, Márquez M, Herrera MF. Bariatric surgery in Mexico: training, practice and surgical trends. Updates Surg 2021; 73:1509-1514. [PMID: 33687693 DOI: 10.1007/s13304-021-01013-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/22/2021] [Indexed: 01/12/2023]
Abstract
Bariatric surgery is extremely safe and effective, but several factors need to be addressed to obtain such results. Patient selection, type of training, accreditation, type of practice, and surgical trends and technique are involved in this process. Local and global standardization are ill-advised, especially in countries with high obesity prevalence, and where the bariatric practice is fast growing.An online survey with 22 questions was sent to bariatric surgeons in Mexico. Only participants with the active practice were included, and the aim was to obtain for the first time insight in bariatric surgery training, characteristics of current practice and surgical trends.Complete responses from 114 surgeons were obtained. Most were male, under 50 years-old, ≤ 10 years of experience, and practice in low-volume hospitals. Less than half had a 12-month formal training. Gastric bypass and sleeve gastrectomy were the most common procedures. Practice trends like leak tests, use of drains, preoperative weight loss, routine endoscopy, and pharmacological tromboprofilaxis are common. In surgical technique, the gastric bypass and sleeve gastrectomy confection was more homogenic when compared to the one-anastomosis gastric bypass.Complete responses from 114 surgeons were obtained. Most were male, under 50 years-old, ≤ 10 years of experience, and practice in low-volume hospitals. Less than half had a 12-month formal training. Gastric bypass and sleeve gastrectomy were the most common procedures. Practice trends like leak tests, use of drains, preoperative weight loss, routine endoscopy, and pharmacological tromboprofilaxis are common. In surgical technique, the gastric bypass and sleeve gastrectomy confection was more homogenic when compared to the one-anastomosis gastric bypass. An important number of bariatric surgeons in Mexico are young, male, and with < 10 years of practice. The most common techniques performed are gastric bypass and sleeve gastrectomy. Several practices and technique trends are similar to global consensus. Fellowship programs and Board Certification in bariatric surgery are major advances in our country, thus standardization and high-quality practice can be achieved.
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Affiliation(s)
| | | | - Hugo Sánchez
- Hospital General de Zona 1, IMSS, Mexico City, Mexico
| | | | | | - Miguel F Herrera
- Instituto Nacional de La Nutrición Salvador Zubirán, Vasco de Quiroga #15, Tlalpan 14, 000, Mexico City, Mexico.
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11
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Wolvers PJD, Ayubi O, Bruin SC, Hutten BA, Brandjes DPM, Meesters EW, Gerdes VEA. Smoking Behaviour and Beliefs About Smoking Cessation After Bariatric Surgery. Obes Surg 2021; 31:239-249. [PMID: 32803711 PMCID: PMC7808968 DOI: 10.1007/s11695-020-04907-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 08/01/2020] [Accepted: 08/06/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Currently, bariatric surgery is the most effective intervention for treating morbid obesity and its complications. Smoking cessation is likely to improve smoking-related comorbidities and decrease postoperative complications. This study evaluated the smoking behaviour and thoughts about smoking cessation of patients more than 18 months after bariatric surgery. MATERIALS AND METHODS A cross-sectional study was performed in patients who underwent bariatric surgery from July 2012 to December 2013. A questionnaire was used to evaluate smoking status, thoughts about the health benefits of cessation and characteristics of previous quit attempts in current and former smokers. Finally, actual bariatric surgery outcomes were evaluated in current, former and never smokers. RESULTS Six hundred nine patients (response rate 52.0%) were included. Of them, 101 (16.6%) patients were current smokers, 239 (39.2%) former smokers and 269 (44.2%) patients were lifetime never smokers. Compared with former smokers, current smokers were less aware of the beneficial effects of smoking cessation on their general health; 66.4% of the former smokers thought smoking cessation would be much better for general health, compared with 20.6% of current smokers. Total weight loss was 2.8% higher in current smokers compared with former smokers. Actual long-term bariatric surgery outcomes were not significantly different between the groups. CONCLUSION Despite advice to quit smoking and temporary quitting before surgery, a considerable group of bariatric surgery patients continues smoking after surgery. These patients were less aware of the beneficial effects of smoking cessation. This study emphasizes the need for better strategies to increase the number of successful cessations.
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Affiliation(s)
- Paula J. D. Wolvers
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Oranos Ayubi
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Sjoerd C. Bruin
- Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, Netherlands
| | - Barbara A. Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Dees P. M. Brandjes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Eelco W. Meesters
- Department of Internal Medicine, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, Netherlands
| | - Victor E. A. Gerdes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, Netherlands
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12
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Abstract
PURPOSE OF REVIEW This review was conducted to gain insight into the history, present and future of bariatric and/or metabolic surgery and endoscopic treatments of obesity. The challenges that have been overcome, the challenges we still face and our recommendations for the future are discussed. RECENT FINDINGS Over the last few decades, a number of treatment strategies have emerged for the treatment of obesity. Both endoscopic and surgical options are available and they lead to significant weight loss and comorbidity reduction. However, to remain a credible treatment alternative to the obesity pandemic, we need to perform these procedures in much larger numbers than we currently do. Even though significant gains have been made in reducing the morbidity and mortality of surgical interventions, there is further room for improvement, especially when it comes to long-term issues. Due to its impact on almost every single organ system in the human body, bariatric surgery has attracted the attention of academics from a variety of medical disciplines. This has led to a rapidly enlarging body of high-quality scientific literature, supporting its wider use and cost-effectiveness. CONCLUSION Despite the advances made in bariatric surgery, the criteria determining suitability of patients for bariatric surgery in most parts of the world are still based on a consensus agreed upon in the USA in 1991. There is a need to formulate some new consensus and guidelines that would allow for a significant expansion of the pool of patients that can be offered these procedures.
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Affiliation(s)
- Edo O Aarts
- Praeclarum, Obesity Treatment, Oosterbeek, The Netherlands.
| | - Kamal Mahawar
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, UK.
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.
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13
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Surgical resident training program to perform laparoscopic bariatric procedures: Are safety and postoperative outcomes compromised? Cir Esp 2020; 99:200-207. [PMID: 32693919 DOI: 10.1016/j.ciresp.2020.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/23/2020] [Accepted: 05/30/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Laparoscopic bariatric procedures such as laparoscopic Roux-en-Y gastric bypass (LRYGB) are technically demanding and require a long learning curve. Little is known about whether surgical resident (SR) training programs to perform these procedures are safe and feasible. This study aims to evaluate the results of our SR training program to perform LRYGB. METHODS We designed a retrospective study including patients with LRYGB between January 2014 and December 2018, comparing SR results to experienced bariatric surgeons (EBS). In our country, SR have a five-year surgical formative period, and in the fourth year they are trained for 6 months in our bariatric surgery unit, from January to June. In the beginning, they perform different steps of this procedure, to finally complete an LRYGB. We collected demographic data, comorbidities, intraoperative outcomes, and postoperative complications and outcomes after a one-year follow-up. RESULTS Two hundred and eight patients were eligible for inclusion: 67 in group I (SR), and 141 in group II (EBS). Both groups were comparable. There was no statistically significant difference in operating time (166.45min in group I vs. 156.69min in group II; P=0.156). Conversion to open surgery, hospital stay, postoperative complications, and short-term outcomes had no significant differences between the two groups. There was no mortality registered during this period. CONCLUSION Implementation of LRYGB stepwise learning as part of an SR training program is safe, and results are comparable to EBS, without loss of efficiency. Therefore, it is feasible to train SR in bariatric surgery under EBS supervision.
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14
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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15
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Boerlage TCC, Wolvers PJD, Bruin SC, Huibregtse IL, Voermans RP, Fockens P, Hutten BA, Gerdes VEA. Upper endoscopy after Roux-en-Y gastric bypass: diagnostic yield and factors associated with relevant findings. Surg Obes Relat Dis 2020; 16:868-876. [PMID: 32299714 DOI: 10.1016/j.soard.2020.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/15/2020] [Accepted: 03/03/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND After laparoscopic Roux-en-Y gastric bypass many patients present with complaints for which an upper endoscopy is performed. However, often no abnormalities are found. OBJECTIVES To investigate the incidence of relevant findings at upper endoscopy and identify patient characteristics associated with a relevant finding. SETTING A high-volume bariatric center. METHODS A retrospective cohort study was performed. All patients presenting with complaints after laparoscopic Roux-en-Y gastric bypass who consequently underwent a diagnostic upper endoscopy were identified from a prospective endoscopic database. Primary outcomes were the number and type of relevant findings at upper endoscopy and its association with patient characteristics. Relevant findings were defined as abnormalities requiring treatment. RESULTS Ninety-eight (39.2%) of 250 patients had a relevant finding at upper endoscopy, mostly marginal ulcer and stomal stenosis. Male sex (odds ratio [OR] 3.47 [1.12-10.76]), alcohol consumption (OR 7.27 [1.58-33.36]), dysphagia or suspicion of bleeding as referral reason (OR 3.62 [1.54-8.52] and 39.93 [4.96-321.47], respectively, compared with abdominal pain), an abnormal upper gastrointestinal series (OR 6.81 [2.06-22.48]), and no abdominal ultrasound (OR 7.41 [1.48-37.08] compared with a normal ultrasound) were significantly associated with a relevant finding at upper endoscopy. CONCLUSIONS In this study sex, alcohol consumption, referral reason, and prior imaging studies were associated with a relevant finding at upper endoscopy after laparoscopic Roux-en-Y gastric bypass.
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Affiliation(s)
- Thomas C C Boerlage
- Department of Gastroenterology & Hepatology, St. Antonius Hospital, Utrecht, the Netherlands
| | - Paula J D Wolvers
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Sjoerd C Bruin
- Department of Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Inge L Huibregtse
- Department of Gastroenterology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Barbara A Hutten
- Department of Clinical Epidemiology and Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Victor E A Gerdes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Internal Medicine, Spaarne Gasthuis Hoofddorp, the Netherlands
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16
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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17
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First assistant impact on early morbidity and mortality in bariatric surgery. Surg Obes Relat Dis 2019; 15:1541-1547. [DOI: 10.1016/j.soard.2019.06.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 12/21/2022]
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18
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Yoshiyama S, Toiyama Y, Ichikawa T, Shimura T, Yasuda H, Hiro JI, Ohi M, Araki T, Kusunoki M. Laparoscopic diagnosis of retrograde peristalsis and intussusception in Roux-en-Y limb after laparoscopic gastrectomy: A case report. Asian J Endosc Surg 2019; 12:171-174. [PMID: 29871028 DOI: 10.1111/ases.12611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 02/06/2018] [Accepted: 05/07/2018] [Indexed: 12/30/2022]
Abstract
The cause of jejunojejunal intussusception, a rare complication after Roux-en-Y gastric surgery, remains unclear. Here, we present a case of retrograde jejunojejunal intussusception that occurred after laparoscopic distal gastrectomy with Roux-en-Y reconstruction. A 51-year-old woman who had undergone laparoscopic distal gastrectomy and Roux-en-Y reconstruction for early gastric cancer 6 years previously was admitted to our hospital with abdominal pain. Abdominal CT revealed the "target sign," and she was diagnosed as having small bowel intussusception. Laparoscopic surgery resulted in a diagnosis of retrograde intussusception of the distal jejunum of the Roux-en-Y anastomosis with retrograde peristalsis in the same area. The Roux-en-Y anastomosis site and intussuscepted segment were resected laparoscopically. To the best of our knowledge, this is the first report of laparoscopic diagnosis of retrograde peristalsis in the distal jejunum of a Roux-en-Y anastomosis. Additionally, relevant published reports concerning this unusual condition are discussed.
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Affiliation(s)
- Shigeyuki Yoshiyama
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yuji Toiyama
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Ichikawa
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tadanobu Shimura
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiromi Yasuda
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Jun-Ichiro Hiro
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaki Ohi
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Toshimitsu Araki
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
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