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Lin H, Baker JW, Meister K, Lak KL, Martin Del Campo SE, Smith A, Needleman B, Nadzam G, Ying LD, Varban O, Reyes AM, Breckenbridge J, Tabone L, Gentles C, Echeverri C, Jones SB, Gould J, Vosburg W, Jones DB, Edwards M, Nimeri A, Kindel T, Petrick A. American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass. Surg Obes Relat Dis 2024; 20:895-909. [PMID: 39097472 DOI: 10.1016/j.soard.2024.06.002] [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: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). OBJECTIVE This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). METHODS PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. RESULTS Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. CONCLUSIONS This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.
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Affiliation(s)
- Henry Lin
- Department of Surgery, Signature Healthcare, Brockton, Massachusetts.
| | - John W Baker
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Kathleen L Lak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - April Smith
- Department of Pharmacy, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | | | - Geoffrey Nadzam
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lee D Ying
- Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Oliver Varban
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Angel Manuel Reyes
- Department of General Surgery, St. Michael Medical Center, Silverdale, Washington
| | - Jamie Breckenbridge
- Department of General Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Lawrence Tabone
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Charmaine Gentles
- Department of Surgery, Northshore University Hospital, Manhasset, New York
| | | | - Stephanie B Jones
- Department of Anesthesiology, Northwell Health, New Hyde Park, New York
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wesley Vosburg
- Department of Surgery, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Daniel B Jones
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Abdelrahman Nimeri
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tammy Kindel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anthony Petrick
- Department of Surgery, Geisinger Medical Center, Danville, Pennsylvania
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Kermansaravi M, Chiappetta S, Shikora SA, Musella M, Kow L, Aarts E, Abbas SI, Aly A, Aminian A, Angrisani L, Asghar ST, Bashir A, Behrens E, Billy H, Boza C, Brown WA, Caina DO, Carbajo MA, Chevallier JM, Clapp B, Cohen RV, Jazi AHD, De Luca M, Dilemans B, Fried M, Gagner M, Neto MG, Garneau PY, Gawdat K, Ghanem OM, Al Hadad M, Haddad A, ElFawal MH, Herrera MF, Higa K, Himpens J, Husain F, Kasama K, Kassir R, Khoursheed M, Khwaja H, Kristinsson JA, Kroh M, Kurian MS, Lakdawala M, LaMasters T, Lee WJ, Madhok B, Mahawar K, Mahdy T, Almomani H, Melissas J, Miller K, Neimark A, Omarov T, Palermo M, Papasavas PK, Parmar C, Pazouki A, Peterli R, Pintar T, Poggi L, Ponce J, Prasad A, Pratt JSA, Ramos AC, Rezvani M, Rheinwalt K, Ribeiro R, Ruiz-Ucar E, Sabry K, Safadi B, Shabbir A, ShahabiShahmiri S, Stenberg E, Suter M, Taha S, Taskin HE, Torres A, Verboonen S, Vilallonga R, Voon K, Wafa A, Wang C, Weiner R, Yang W, Zundel N, Prager G, Nimeri A. Metabolic and Bariatric Surgeon Criteria-An International Experts' Consensus. Obes Surg 2024; 34:3216-3228. [PMID: 39046625 DOI: 10.1007/s11695-024-07395-y] [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: 04/10/2024] [Revised: 07/03/2024] [Accepted: 07/12/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE With the global epidemic of obesity, the importance of metabolic and bariatric surgery (MBS) is greater than ever before. Performing these surgeries requires academic training and the completion of a dedicated fellowship training program. This study aimed to develop guidelines based on expert consensus using a modified Delphi method to create the criteria for metabolic and bariatric surgeons that must be mastered before obtaining privileges to perform MBS. METHODS Eighty-nine recognized MBS surgeons from 42 countries participated in the Modified Delphi consensus to vote on 30 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. RESULTS Consensus was reached on 29 out of 30 statements. Most experts agreed that before getting privileges to perform MBS, surgeons must hold a general surgery degree and complete or have completed a dedicated fellowship training program. The experts agreed that the learning curves for the various operative procedures are approximately 25-50 operations for the LSG, 50-75 for the OAGB, and 75-100 for the RYGB. 93.1% of experts agreed that MBS surgeons should diligently record patients' data in their National or Global database. CONCLUSION MBS surgeons should have a degree in general surgery and have been enrolled in a dedicated fellowship training program with a structured curriculum. The learning curve of MBS procedures is procedure dependent. MBS surgeons must demonstrate proficiency in managing postoperative complications, collaborate within a multidisciplinary team, commit to a minimum 2-year patient follow-up, and actively engage in national and international MBS societies.
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Affiliation(s)
- Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Hazrat-E Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | | | - Scott A Shikora
- Department of Surgery, Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mario Musella
- Advanced Biomedical Sciences Department, Federico II" University, Naples, Italy
| | - Lilian Kow
- Adelaide Bariatric Centre, Flinders University of South Australia, Adelaide, Australia
| | - Edo Aarts
- Weight Works Clinics and Allurion Clinics, Amersfoort, The Netherlands
| | | | - Ahmad Aly
- Austin and Repatriation Medical Centre, University of Melbourne, Heidelberg, VIC, Australia
| | - Ali Aminian
- Director, Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Luigi Angrisani
- Department of Public Health, Federico II University of Naples, Naples, Italy
| | | | - Ahmad Bashir
- Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Amman, Jordan
| | | | - Helmuth Billy
- Ventura Advanced Surgical Associates, Ventura, CA, USA
| | - Camilo Boza
- Nutrition and Bariatric Center, Clinica Las Condes, Santiago de Chile, Chile
| | - Wendy A Brown
- Department of Surgery, Central Clinical School, Alfred Health, Monash University, Melbourne, VIC, Australia
| | - Daniel Oscar Caina
- Dr. Federico Abete Hospital for Trauma and Emergency, Obesity and Metabolic Center, Malvinas, Argentina
| | | | | | - Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX, USA
| | - Ricardo V Cohen
- Center for the Treatment of Obesity and Diabetes, Hospital Alemão Oswaldo Cruz, Sao Paolo, Brazil
| | - Amir Hossein Davarpanah Jazi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Hazrat-E Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Bruno Dilemans
- Department of General Surgery, Sint Jan Brugge-Oostende, Brugge, AZ, Belgium
| | | | - Michel Gagner
- Department of Surgery, Westmount Square Surgical Center, Westmount, QC, Canada
| | | | - Pierre Y Garneau
- Division of Bariatric Surgery, CIUSSS-NIM, Montreal, Canada
- Department of Surgery, Université de Montréal, Montréal, Canada
| | - Khaled Gawdat
- Bariatric Surgery Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Omar M Ghanem
- Division of Metabolic & Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Ashraf Haddad
- Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Amman, Jordan
| | | | - Miguel F Herrera
- Endocrine and Bariatric Surgery, UNAM at INCMNSZ, Mexico City, México
| | - Kelvin Higa
- Fresno Heart and Surgical Hospital, UCSF Fresno, Fresno, CA, USA
| | - Jaques Himpens
- Bariatric Surgery Unit, Delta Chirec Hospital, Brussels, Belgium
| | - Farah Husain
- University of Arizona College of Medicine, Phoenix, USA
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Radwan Kassir
- Digestive and Bariatric Surgery Department, The View Hospital, Doha, Qatar
| | | | - Haris Khwaja
- Department of Bariatric and Metabolic Surgery, Chelsea and Westminster Hospital, London, UK
| | - Jon A Kristinsson
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
| | - Matthew Kroh
- Foregut Surgery and Surgical Endoscopy, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marina S Kurian
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Muffazal Lakdawala
- Department of General Surgery and Minimal Access Surgical Sciences, Sir H.N. Reliance Foundation Hospital, Mumbai, India
| | - Teresa LaMasters
- UnityPoint Clinic Weight Loss Specialists, West Des Moines, IA, USA
| | - Wei-Jei Lee
- Medical Weight Loss Center, China Medical University Shinchu Hospital, Zhubei City, Taiwan
| | - Brijesh Madhok
- East Midlands Bariatric and Metabolic Institute, University Hospital of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Kamal Mahawar
- South Tyneside and Sunderland Foundation NHS Trust, Sunderland, UK
| | - Tarek Mahdy
- Department of Bariatric Surgery, Sharjah University, Sharjah, UAE
| | | | - John Melissas
- Bariatric Unit, Heraklion University Hospital, University of Crete, Crete, Greece
| | - Karl Miller
- Diakonissen Wehrle Private Hospital, Salzburg, Austria
| | - Alexander Neimark
- Laboratory of Surgery for Metabolic Disorders, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Taryel Omarov
- Department of Surgery, Azerbaijan Medical University, Baku, Azerbaijan
| | - Mariano Palermo
- Department of Surgery, Centro CIEN-Diagnomed, University of Buenos Aires, Buenos Aires, Argentina
| | - Pavlos K Papasavas
- Division of Metabolic and Bariatric Surgery, Hartford Hospital, Hartford, CT, USA
| | | | - Abdolreza Pazouki
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Hazrat-E Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ralph Peterli
- Department of Visceral Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, St. Claraspital, and University Hospital Basel, Basel, Switzerland
| | - Tadeja Pintar
- Department of Abdominal Surgery and Medical Faculty, UMC Ljubljana, Ljubljana, Slovenia
| | - Luis Poggi
- Department of Surgery Clinica Anglo Americana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Jaime Ponce
- Bariatric Surgery Program, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Arun Prasad
- Department of Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Janey S A Pratt
- Department of Surgery, Stanford School of Medicine, VA Palo Alto Health Care System, 3801 Miranda Avenue, GS 112, Palo Alto, CA, 94304, USA
| | | | - Masoud Rezvani
- Department of Surgery, Davis Hwy, Inova Fair Oaks Hospital, JeffersonSuite 205, Woodbridge, VA, 14904, USA
| | | | - Rui Ribeiro
- Centro Multidisciplinar Do Tratamento da Obesidade, Hospital Lusíadas Amadora E Lisbon, Amadora, Portugal
| | - Elena Ruiz-Ucar
- Department of Bariatric and Endocrine Surgery, Fuenlabrada University Hospital, Madrid, Spain
| | - Karim Sabry
- Department of Surgery, Ain Shams University, Ain Shams, Egypt
| | | | - Asim Shabbir
- National University of Singapore, Singapore, Singapore
| | - Shahab ShahabiShahmiri
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Hazrat-E Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Michel Suter
- Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Safwan Taha
- Mediclinic Hospital Airport Road, Abu Dhabi, UAE
| | - Halit Eren Taskin
- Department of Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Antonio Torres
- Professor of Surgery, Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Calle del Prof Martín Lagos, S/N, 28040, Madrid, Spain
| | | | - Ramon Vilallonga
- Endocrine, Bariatric, and Metabolic Surgery Department, University Hospital Vall Hebron, Barcelona, Spain
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Ala Wafa
- Aljazeera International Hospital, Misurata University School of Medicine, Misurata, Libya
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | | | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Natan Zundel
- Department of Surgery, State University of New York, Buffalo, NY, USA
| | - Gerhard Prager
- Department of Surgery, Vienna Medical University, Vienna, Austria
| | - Abdelrahman Nimeri
- Department of Surgery, Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Director of Bariatric and Metabolic Surgery, Harvard Medical School, Boston, MA, USA
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3
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Chow MS, Gordon AJ, Talwar A, Lydiatt WM, Yueh B, Givi B. The RVU Compensation Model and Head and Neck Surgical Education. Laryngoscope 2024; 134:113-119. [PMID: 37289069 DOI: 10.1002/lary.30807] [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: 01/20/2023] [Revised: 05/04/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND The present study aims to quantify the opportunity cost of training residents and fellows for head and neck surgery. METHODS A 2005-2015 review of ablative head and neck surgical procedures was performed using the National Surgical Quality Improvement Program (NSQIP). Work relative value units (wRVU) generated per hour were compared among procedures performed by attendings alone, attendings with residents, and attendings with fellows. RESULTS Among 34,078 ablative procedures, the rate of wRVU generation per hour was greatest for attendings alone (10.3), followed by attendings with residents (8.9) and attendings with fellows (7.0, p < 0.001). Resident and fellow involvement was associated with opportunity costs of $60.44 per hour (95% CI: $50.21-$70.66/h) and $78.98 per hour ($63.10-$94.87/h, 95% CI), respectively. CONCLUSION wRVU-based physician reimbursement does not consider or adjust for the extra effort involved in training future head and neck surgeons. LEVEL OF EVIDENCE NA Laryngoscope, 134:113-119, 2024.
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Affiliation(s)
- Michael S Chow
- Department of Otolaryngology, Head and Neck Surgery, New York University, New York, New York, USA
| | - Alex J Gordon
- Grossman School of Medicine, New York University, New York, New York, USA
| | - Abhinav Talwar
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - William M Lydiatt
- Methodist-Creighton Head and Neck, Creighton University, Omaha, Nebraska, USA
| | - Bevan Yueh
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Babak Givi
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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4
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Hoagland D, Olasky J, Kent TS, Vosburg RW. The Impact of Trainee Involvement on Outcomes in Metabolic and Bariatric Surgery. Obes Surg 2023; 33:3454-3462. [PMID: 37755646 DOI: 10.1007/s11695-023-06831-9] [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: 07/11/2023] [Revised: 08/24/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND The number of bariatric operations performed in the USA rises annually. Trainee exposure to this field is necessary to ensure competency in future surgical generations. However, the safety of trainee involvement of these operations has been called into question. OBJECTIVES The aim of our study is to describe differences in outcomes between trainees and non-trainees as first assistants (FA) in sleeve gastrectomy (SG). SETTING The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database METHODS: Patients from the MBSAQIP database who underwent primary SG from 2015 to 2020 were identified. Statistical analysis included two-tailed t-tests and χ2-tests to evaluate the impact of trainees (residents and fellows) compared to non-trainees on post-operative morbidity and operative time. RESULTS Of the 559,324 cases, 25.8% were performed with trainees as FA. Operative length was 27.9% longer in trainee cases. In the trainee group, there was a higher risk of conversion to open procedure (OR 1.32), readmission (OR 1.19), and specific complications (cardiac arrest, myocardial infarction, progressive renal insufficiency, pulmonary embolism, sepsis, transfusion, intubation, UTI, VTE, ICU admission, and reintervention), though overall rates were < 1% in each group. Non-trainees had a higher rate of septic shock (OR 1.4). No significant difference was seen in all other perioperative outcomes. CONCLUSION Trainee involvement in SG leads to longer operative times without a clinically significant increase in morbidity and mortality. Such findings should be used to counsel patients and shape expectations for surgeons and hospitals. A focused bariatric surgery trainee curriculum may lessen this gap.
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Affiliation(s)
- Darian Hoagland
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Jaisa Olasky
- Department of Surgery, Lenox Hill Hospital, New York, USA
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - R Wesley Vosburg
- Department of surgery Mount Auburn Hospital, Harvard Medical School, 355 Waverley Oaks rd, suite 100, Waltham, MA, 02452, USA.
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Lima DL, Profeta RD, Berk R, Pereira X, Moran-Atkin E, Choi J, Camacho D. Outcomes in Minimally Invasive Sleeve Gastrectomy and Implications for Surgical Resident Education. J Laparoendosc Adv Surg Tech A 2023; 33:846-851. [PMID: 37432795 DOI: 10.1089/lap.2023.0080] [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] [Indexed: 07/13/2023] Open
Abstract
Introduction: Resident participation in advanced minimally invasive and bariatric surgeries is controversial. The aim of this study is to evaluate the safety of resident participation in robotic and laparoscopic sleeve gastrectomy (SG). Methods: Prospectively maintained institutional Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database was used to identify patients who underwent SG, which was performed at our institution between January, 2018, and December, 2021. Operative notes were reviewed to determine the training level of the assistant. These were then classified into 7 groups: postgraduate years 1-5 residents, bariatric fellow (6), and attending surgeons (7). Each group was stratified and their outcomes, which included duration of surgery, length of stay (LOS), postoperative complications, readmissions, and reoperations, were compared. Results: Out of 2571 cases, the assistants for the procedures were minimally invasive surgery (MIS) fellows (n = 863, 58.8%), fifth- and fourth-year residents (n = 228, 15.5%), third- and second-year residents (n = 164, 11.2%), no assistants (n = 212, 14.5%), and 134 robotic SG. Mean body mass index was higher in cases wherein the attending surgeon performed by himself (47.1, standard deviation 7.7) when compared with other groups. There were no conversions to open. Mean LOS was 1.3 days, and there was no difference between groups (P = .242). Postoperative complications were low, with 11 reoperations in 30 days (3.3%) and no difference between groups. There was no mortality in 30 or 90 days. Conclusion: Postoperative outcomes were similar for patients who underwent SG regardless of the assistant's level of training. Including residents in bariatric procedures is safe and does not affect patient safety. Encouraging residents to participate in complex MIS procedures is recommended as part of their training.
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Affiliation(s)
- Diego L Lima
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
| | | | - Robin Berk
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
| | - Xavier Pereira
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
| | - Erin Moran-Atkin
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
| | - Jenny Choi
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
| | - Diego Camacho
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
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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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7
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Edwards MA, Terhaar H, Spaulding A. Resident first assistance in bariatric surgery: do patients pay a price? Surg Obes Relat Dis 2022; 18:738-746. [DOI: 10.1016/j.soard.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/13/2022] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
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Landin MD, Gordee A, Lerebours RC, Kuchibhatla M, Eckhouse SR, Seymour KA. Trends in Risk Factors for Readmission after Bariatric Surgery 2015-2018. Surg Obes Relat Dis 2022; 18:581-593. [DOI: 10.1016/j.soard.2021.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/26/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022]
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9
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Crawford DA, Berend KR, Lombardi AV. Fellow Involvement in Primary Total Knee Arthroplasty: Is There an "August Effect?". J Knee Surg 2022; 35:83-90. [PMID: 32559787 DOI: 10.1055/s-0040-1713113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to determine if a fellow's involvement, as well as duration of a fellow's training, impacts complications, outcomes, and survivorship in primary total knee arthroplasty (TKA). A retrospective review identified 2,790 consecutive patients (3,530 knees) who underwent primary TKA between 2003 and 2008. A 2-year minimum follow-up was available on 2,785 knees (2,195 patients). Operative data, clinical outcomes, complications, and survivorship were compared between cases with and without a fellow involved as well as comparing cases in the first quarter (Q1) of the academic year to the last three quarters (Q2-4). Mean follow-up was 9.7 years. Fellows were involved in 1,434 (41%) surgeries. Fellow cases had significantly longer tourniquet times (59.5 vs. 49 minutes, p < 0.001) and operative times (82.4 vs. 70.8 minutes, p < 0.001). Overall, there was no difference in clinical, functional, or pain outcomes between attending and fellow cases. Fellow cases during Q1 had significantly worse pain scores (p = 0.009) and clinical scores (p < 0.001). Revision rate, infection rates, and survivorship were not significantly different between fellow and attendings or during Q1 of fellowship compared with attendings. Primary TKA survivorship and complications were not affected by fellow involvement or academic quarter. An "August Effect" may be suggested for clinical and pain outcomes in the first 3 months of fellowship.
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Affiliation(s)
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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10
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Yuce TK, Holmstrom A, Soper NJ, Nagle AP, Hungness ES, Merkow RP, Teitelbaum EN. Complications and Readmissions Associated with First Assistant Training Level Following Elective Bariatric Surgery. J Gastrointest Surg 2021; 25:1948-1954. [PMID: 32930915 PMCID: PMC7956903 DOI: 10.1007/s11605-020-04787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little is known regarding the variation in training level and potential clinical impact of the first assistant in bariatric surgery. We describe the postoperative 30-day complications and readmissions following elective bariatric procedures by training level of the first assistant. METHODS The ACS-MBSAQIP database was queried to identify patients who underwent elective sleeve gastrectomy, Roux-En-Y gastric bypass, duodenal switch, band placement, and revision from 2015 to 2016. Patients were divided into cohorts based on training level of the first assistant (attending, fellow, resident, physician assistant/nurse practitioner, none). Outcomes included 30-day death or serious morbidity (DSM) and readmission. Multivariable logistic regression models, adjusting for patient and procedure characteristics, were estimated to examine differences in outcomes by first assistant training level. RESULTS Of 410,535 procedures performed between 2015 and 2016, the training level of the first assistant included 21.3% attending, 8.7% fellow, 16.5% resident, 37.6% PA/NP, and 15.9% none. Operative time was significantly longer in the fellow and resident first assistant cohorts when compared with all other cohorts. Overall rates of 30-day DSM were low, ranging from 3.2 to 3.8%, while 30-day readmission rates ranged from 5.1 to 5.9%. Following adjustment for patient characteristics and type of procedure, first assistant training level had no significant impact on DSM or readmission. CONCLUSIONS Variation in training level of the first assist during bariatric surgery had no influence on DSM or readmissions. This provides reassurance that the inclusion of a wide range of first assistants in bariatric procedures does not negatively impact patient outcomes.
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Affiliation(s)
- Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amy Holmstrom
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nathaniel J Soper
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alexander P Nagle
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric S Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ezra N Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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11
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Valente M, Campanelli M, Benavoli D, Arcudi C, Riccó M, Bianciardi E, Gentileschi P. Safety and Outcomes of Laparoscopic Sleeve Gastrectomy in a General Surgery Residency Program. JSLS 2021; 25:JSLS.2020.00063. [PMID: 33879991 PMCID: PMC8035819 DOI: 10.4293/jsls.2020.00063] [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] [Indexed: 12/25/2022] Open
Abstract
Background: With the escalation of surgical treatment of morbid obesity, there is a growing interest in the training of bariatric surgeons. Laparoscopic sleeve gastrectomy (LSG) gained popularity both as a first-stage approach and as a stand-alone procedure. Objectives: The aim of this study was to assess detectable differences in LSG with intra-operative resident involvement. Methods: We reviewed obese patients, who had undergone LSG between January 1, 2017 and January 31, 2020. Collected data reported demographic factors, operative time, postoperative complications, and outcomes. Results: Among 313 patients who met the inclusion criteria, 94 were men and 219 were women. The procedures were performed either by an expert bariatric surgeon (group 1), or a general surgery resident (group 2), respectively in 228 and 85 cases. Mean operative time of the first group was 65.3 ± 18.8 minutes, while it was 74.3 ± 17.2 among trainees (p < 0.001). Perioperative complications were diagnosed in 13 patients (10 in group 1 and 3 in group 2). Mean excess body weight loss after 12 months was 87.7 ± 28.2% in the first group and 81.1 ± 31.6% in the residents group. Between the two groups, we found no differences in the incidence of perioperative complications and in surgical outcomes. Trainee involvement was associated with increased operative time, with no correlation with a worse postoperative course. Conclusions: Residents can safely perform LSG in referral centers under the supervision of an expert bariatric surgeon. Trainee involvement is not related to increased leak rate, nor to suboptimal short-term outcome.
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Affiliation(s)
- Marina Valente
- Obesity Unit, Department of Surgery, University of Rome Tor Vergata, Roma, Italy
| | - Michela Campanelli
- Obesity Unit, Department of Surgery, University of Rome Tor Vergata, Roma, Italy
| | - Domenico Benavoli
- Obesity Unit, Department of Surgery, University of Rome Tor Vergata, Roma, Italy
| | - Claudio Arcudi
- Obesity Unit, Department of Surgery, University of Rome Tor Vergata, Roma, Italy
| | | | | | - Paolo Gentileschi
- Obesity Unit, Department of Surgery, University of Rome Tor Vergata, Roma, Italy
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12
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Edgerton C, Heshmati K, Herman A, Dey T, Dehkharghani R, Ramsis R, Robinson M, Vernon A, Ghushe N, Spector D, Shikora S, Tavakkoli A, Sheu EG. Fellowship training influences learning curves for laparoscopic sleeve gastrectomy. Surg Endosc 2021; 36:1601-1608. [PMID: 33620566 DOI: 10.1007/s00464-021-08372-7] [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: 08/15/2020] [Accepted: 02/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure. Little is known about how surgeon training background influences the learning curve of this procedure. We examined operating times (OT), weight loss outcomes, and 30-day complications between surgeons with and without fellowship training in LSG. We hypothesize that post-residency training specific to LSG influences learning curves. METHODS Surgeons from a single institution were split into two groups: those who had not completed fellowship training in LSG (NF, n = 3), and those who had completed LSG specific training in fellowship (SGF, n = 3). OTs, BMI changes at 1 year, and 30-day readmissions, reoperations, and complications were extracted for the first 100 LSG cases of each surgeon. Data were analyzed in bins of 20 cases. Comparisons were made between cohorts within a bin and between adjacent bins of the same surgeon cohort. Logistic regression analyses were performed of OT and weight loss outcomes. RESULTS SGF surgeons showed no difference in OTs over their first 100 cases. NF surgeons had statistically significant increased OTs compared to SGF surgeons during their first 60 cases and progressively shortened OTs during that interval (109 min to 78 min, p < 0.001 for NF surgeons vs. 73 min to 69 min, SGF surgeons). NF surgeons had a significantly steeper slope for improvement in OT over case number. There was no correlation between case number and weight loss outcomes in either group, and no differences in 30-day outcomes between groups. CONCLUSION Surgeons who trained to perform LSG in fellowship demonstrate faster and consistent OR times on their initial independent LSG cases compared to surgeons who did not, with no correlation between case number and weight loss outcomes or safety profiles for either group. This suggests that learning curves for LSG are achieved during formal case-specific fellowship training.
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Affiliation(s)
- Colston Edgerton
- Division of Gastrointestinal Surgery, Center for Metabolic and Bariatric Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Keyvan Heshmati
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ashley Herman
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Tanujit Dey
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Robab Dehkharghani
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ramsis Ramsis
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Malcolm Robinson
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ashley Vernon
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Neil Ghushe
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - David Spector
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Scott Shikora
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ali Tavakkoli
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Eric G Sheu
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. .,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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13
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Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures. Surg Endosc 2020; 35:4618-4623. [PMID: 32789589 PMCID: PMC8823948 DOI: 10.1007/s00464-020-07887-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/05/2020] [Indexed: 12/22/2022]
Abstract
Introduction The use of bariatric surgery in the management of obesity and its related morbidity has significantly increased in the US over the past decade. There is a lack of data on the impact of optimal preoperative glycemic control on the morbidity and mortality following bariatric surgery. The aim of this study was to analyze the impact of hemoglobin (Hb) A1c > 7 on outcomes among patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Methods Data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (2017) and limited to patients undergoing an elective laparoscopic RYGB or SG. Multivariable logistic regression was conducted to adjust for other preoperative variables. Results A total number of 31,060 (69.3%) patients underwent SG, while 13,754 (30.7%) received RYGB. Patients who were older, male, non-Hispanic, smokers, and those with a higher American Society of Anesthesiologist Classification (ASA) score were more likely to have elevated HbA1c levels. Compared to individuals with normal HbA1c levels, patients with elevated levels had no significant difference in mortality (p = 0.902) but did have a difference in composite morbidity and mortality (p < 0.001). On multivariable analysis, elevated HbA1c, older age, increasing body mass index (BMI), elevated creatinine, longer operations, African American race, receiving RYGB, and having a trainee as surgical assistant were found to increase the odds of having an adverse outcome. No significant difference was found within smoking status, sex, ASA Classification, robotic vs laparoscopic, or if a second attending surgeon was assisting. Conclusions HbA1c levels and presence of trainees in the OR are modifiable preoperative risk factors for adverse events following bariatric surgery. Improving preoperative glycemic control may be an effective and achievable quality improvement measure.
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14
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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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15
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Barbat SD, Thompson KJ, Raheem E, Mckillop IH, Dugan N, Nimeri A. Bariatric surgery outcomes when assisted by fellows and residents: an MBSAQIP analysis of 477,670 patients. Surg Obes Relat Dis 2020; 16:651-657. [DOI: 10.1016/j.soard.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/13/2019] [Accepted: 01/14/2020] [Indexed: 01/03/2023]
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16
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Andalib A, Bouchard P, Bougie A, Loiselle SE, Demyttenaere S, Court O. Variability in Bariatric Surgical Care Among Various Centers: a Survey of All Bariatric Surgeons in the Province of Quebec, Canada. Obes Surg 2019; 28:2327-2332. [PMID: 29492752 DOI: 10.1007/s11695-018-3157-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Despite an increase in bariatric surgery across Quebec, Canada, access is still limited. Furthermore, there are differences in resources and multidisciplinary capabilities of providing centers that may impact quality of care and outcomes. METHODS We performed an online survey of all bariatric surgeons in the province of Quebec, Canada, using the LimeSurvey software. RESULTS Forty-six surgeons from 15 centers were surveyed. Response rate was 87% (n = 40). Only 13 (35%) surgeons have any formal fellowship training in bariatric surgery and 74% perform > 50 cases/year. All surgeons perform sleeve gastrectomy, 34% do duodenal switch, and 44% provide major revisions. Thirty-one surgeons (77%) identified access to operating room as the main cause for surgical delays. While most surgeons (52%) considered < 6 months as an acceptable wait-time, only 33% achieved this in their practice. Majority (70%) favored a centralized provincial referral system. Patient's geographical convenience, procedural choice, and multidisciplinary capabilities of providing centers are identified as important determinants for centralized referrals (93, 78, and 55%, respectively). Virtually, all supported accreditation/designation of centers and creation of Quebec Bariatric Network for quality control and research (85 and 98%, respectively). CONCLUSION Bariatric surgical patterns vary among designated centers in Quebec, Canada. Access to multidisciplinary care and surgeon's fellowship training may be contributing factors for the observed variability. Wait-lists are long and timely access to surgery remains an issue. There is near consensus for establishing a centralized referral system, designation of referral vs. primary centers, and creating Quebec Bariatric Network for research and quality control.
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Affiliation(s)
- Amin Andalib
- Center for Bariatric Surgery, Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada. .,Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, Room: E16-152, Montreal, QC, H3G 1A4, Canada.
| | - Philippe Bouchard
- Center for Bariatric Surgery, Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Alexandre Bougie
- Center for Bariatric Surgery, Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Sarah-Eve Loiselle
- Center for Bariatric Surgery, Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Sebastian Demyttenaere
- Center for Bariatric Surgery, Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Olivier Court
- Center for Bariatric Surgery, Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
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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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Ghiassi S. Comment on: Operative time as a marker of quality in bariatric surgery. Surg Obes Relat Dis 2019; 15:1120-1121. [PMID: 31427105 DOI: 10.1016/j.soard.2019.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Saber Ghiassi
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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19
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Khorgami Z, De La Cruz-Muñoz N. Comment on: "Racial disparities in perioperative outcomes after bariatric surgery". Surg Obes Relat Dis 2019; 15:804-805. [PMID: 31005459 DOI: 10.1016/j.soard.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Zhamak Khorgami
- Department of Surgery, University of Oklahoma College of Medicine - Tulsa, Tulsa, Oklahoma
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20
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Goldberg I, Yang J, Park J, Pryor AD, Docimo S, Bates AT, Talamini MA, Spaniolas K. Surgical trainee impact on bariatric surgery safety. Surg Endosc 2018; 33:3014-3025. [DOI: 10.1007/s00464-018-6587-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 11/07/2018] [Indexed: 12/13/2022]
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Groves DK, Altieri MS, Sullivan B, Yang J, Talamini MA, Pryor AD. The Presence of an Advanced Gastrointestinal (GI)/Minimally Invasive Surgery (MIS) Fellowship Program Does Not Impact Short-Term Patient Outcomes Following Fundoplication or Esophagomyotomy. J Gastrointest Surg 2018; 22:1870-1880. [PMID: 29980972 DOI: 10.1007/s11605-018-3704-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/25/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The current surgical landscape reflects a continual trend towards sub-specialization, evidenced by an increasing number of US surgeons who pursue fellowship training after residency. Despite this growing trend, however, the effect of advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs on patient outcomes following foregut/esophageal operations remains unclear. This study looks at two representative foregut surgeries (laparoscopic fundoplication and esophagomyotomy) performed in New York State (NYS), comparing hospitals which do and do not possess a GI/MIS fellowship program, to examine the effect of such a program on perioperative outcomes. We also aimed to identify any patient or hospital factors which might influence perioperative outcomes. METHODS The SPARCS database was examined for all patients who underwent a foregut procedure (specifically, either an esophagomyotomy or a laparoscopic fundoplication) between 2012 and 2014. We compared the following outcomes between institutions with and without a GI/MIS fellowship program: 30-day readmission, hospital length of stay (LOS), and development of any major complication. RESULTS There were 3175 foregut procedures recorded from 2012 to 2014. Just below one third (n = 1041; 32.8%) were performed in hospitals possessing a GI/MIS fellowship program. Among our entire included study population, 154 patients (4.85%) had a single 30-day readmission, with no observed difference in readmission between hospitals with and without a GI/MIS fellowship program, even after controlling for potential confounding factors (p = 0.6406 and p = 0.2511, respectively). Additionally, when controlling for potential confounders, the presence/absence of a GI/MIS fellowship program was found to have no association with risk of having a major complication (p = 0.1163) or LOS (p = 0.7562). Our study revealed that postoperative outcomes were significantly influenced by patient race and payment method. Asians and Medicare patients had the highest risk of suffering a severe complication (10.00 and 7.44%; p = 0.0311 and p = 0.0036, respectively)-with race retaining significance even after adjusting for potential confounders (p = 0.0276). Asians and uninsured patients demonstrated the highest readmission rates (15.00 and 12.50%; p = 0.0129 and p = 0.0012, respectively)-with both race and payment method retaining significance after adjustment (p = 0.0362 and p = 0.0257, respectively). Lastly, payment method was significantly associated with postoperative LOS (p < 0.0001), with Medicaid patients experiencing the longest LOS (mean 3.99 days) and those with commercial insurance experiencing the shortest (mean 1.66 days), a relationship which retained significance even after adjusting for potential confounders (p < 0.0001). CONCLUSION The presence of a GI/MIS fellowship program does not impact short-term patient outcomes following laparoscopic fundoplication or esophagomyotomy (two representative foregut procedures). Presence of such a fellowship should not play a role in choosing a surgeon. Additionally, in these foregut procedures, patient race (particularly Asian race) and payment method were found to be independently associated with postoperative outcomes, including postoperative LOS.
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Affiliation(s)
- Donald K Groves
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA.
| | - Maria S Altieri
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Brianne Sullivan
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Jie Yang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Mark A Talamini
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
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Kaijser M, van Ramshorst G, van Wagensveld B, Pierie JP. Current Techniques of Teaching and Learning in Bariatric Surgical Procedures: A Systematic Review. JOURNAL OF SURGICAL EDUCATION 2018; 75:730-738. [PMID: 29033273 DOI: 10.1016/j.jsurg.2017.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/26/2017] [Accepted: 09/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The gastric sleeve resection and gastric bypass are the 2 most commonly performed bariatric procedures. This article provides an overview of current teaching and learning methods of those techniques in resident and fellow training. DESIGN A database search was performed on Pubmed, Embase, and the Education Resources Information Center (ERIC) to identify the methods used to provide training in bariatric surgery worldwide. After exclusion based on titles and abstracts, full texts of the selected articles were assessed. Included articles were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS In total, 2442 titles were identified and 14 full text articles met inclusion criteria. Four publications described an ex vivo training course, and 6 focused on at least 1 step of the gastric bypass procedure. Two randomized controlled trials (RCT) provided high-quality evidence on training aspects. Surgical coaching caused significant improvement of Bariatric Objective Structured Assessment of Technical Skills (BOSATS) scores (3.60 vs. 3.90, p = 0.017) and reduction of technical errors (18 vs. 10, p = 0.003). A preoperative warm-up increased global rating scales (GRS) scores on depth perception (p = 0.02), bimanual dexterity (p = 0.01), and efficiency of movements (p = 0.03). CONCLUSION Stepwise education, surgical coaching, warming up, Internet-based knowledge modules, and ex vivo training courses are effective in relation to bariatric surgical training of residents and fellows, possibly shortening their learning curves.
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Affiliation(s)
- Mirjam Kaijser
- University of Groningen, University Medical Centre Groningen, Post Graduate School of Medicine, Groningen, The Netherlands; Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands; Heelkunde Friesland Groep, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
| | - Gabrielle van Ramshorst
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Bart van Wagensveld
- Department of Surgery, Onze Lieve Vrouwe Gasthuis West, Amsterdam, The Netherlands
| | - Jean-Pierre Pierie
- University of Groningen, University Medical Centre Groningen, Post Graduate School of Medicine, Groningen, The Netherlands; Heelkunde Friesland Groep, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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23
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van Ramshorst GH, Kaijser MA, Pierie JPEN, van Wagensveld BA. Resident Training in Bariatric Surgery-A National Survey in the Netherlands. Obes Surg 2018; 27:2974-2980. [PMID: 28560526 PMCID: PMC5651706 DOI: 10.1007/s11695-017-2729-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose Surgical procedures for morbid obesity, including laparoscopic Roux-en-Y gastric bypass (LRYGB), are considered standardized laparoscopic procedures. Our goal was to determine how bariatric surgery is trained in the Netherlands. Materials and Methods Questionnaires were sent to lead surgeons from all 19 bariatric centers in the Netherlands. At least two residents or fellows were surveyed for each center. Dutch residents are required to collect at least 20 electronic Objective Standard Assessment of Technical Skills (OSATS) observations per year, which include the level of supervision needed for specific procedures. Centers without resident accreditation were excluded. Results All 19 surgeons responded (100%). Answers from respondents who worked at teaching hospitals with residency accreditation (12/19, 63%) were analyzed. The average number of trained residents or fellows was 14 (range 3–33). Preferred procedures were LRYGB (n = 10), laparoscopic gastric sleeve (LGS) resection (n = 1), or no preference (n = 1). Three groups could be discerned for the order in which procedural steps were trained: unstructured, in order of increasing difficulty, or in order of chronology. Questionnaire response was 79% (19/24) for residents and 73% (8/11) for fellows. On average, residents started training in bariatric surgery in postgraduate year (PGY) 4 (range 0–5). The median number of bariatric procedures performed was 40 for residents (range 0–148) and 220 during fellowships (range 5–306). Conclusions Training in bariatric surgery differs considerably among centers. A structured program incorporating background knowledge, step-wise technical skills training, and life-long learning should enhance efficient training in bariatric teaching centers without affecting quality or patient safety.
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Affiliation(s)
- Gabrielle H van Ramshorst
- VU University Medical Center, Amsterdam, the Netherlands. .,The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, the Netherlands.
| | - Mirjam A Kaijser
- Department of Surgery, MCL Leeuwarden, Leeuwarden, the Netherlands.,PGSOM, UMCG/RU Groningen, Groningen, the Netherlands
| | - Jean-Pierre E N Pierie
- Department of Surgery, MCL Leeuwarden, Leeuwarden, the Netherlands.,PGSOM, UMCG/RU Groningen, Groningen, the Netherlands
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The impact of fellowship surgical training on operative time and patient morbidity during robotics-assisted sacrocolpopexy. Int Urogynecol J 2017; 29:1317-1323. [PMID: 28889173 DOI: 10.1007/s00192-017-3468-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/21/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolapse (POP) in the USA. Over the last decade, fellowship programs have increased the number of these procedures performed robotically. Currently, there is a paucity of literature exploring the impact of fellowship training on outcomes of robotic-assisted sacrocolpopexy (RASC). We sought to explore the impact of an expert surgeon operating alone versus with a fellow on operative time and perioperative morbidity associated with RASC. METHODS This is an analysis of a retrospectively collected cohort of all RASCs performed to treat POP from June 2010 to August 2015 by a single attending surgeon. Outcomes were compared by expert surgeon alone and with a fellow. RESULTS We identified 208 RASCs, of which 124 (59.6%) were performed by an expert surgeon alone and 84 (40.4%) with a fellow. Eight fellows were included, with a median of 7 cases (interquartile range 5-13.5). Cases with fellows were 31.1 min longer than an expert surgeon alone (155.6 vs 124.5 min, p < 0.001), a 25% increase. Increased operative time for fellows remained significant on multivariate regression (34.2 min, p < 0.001) after adjusting for case order postmenopausal status, hysterectomy, mid-urethral sling, and bowel injury. Years in fellowship did not have an impact on operative time (p = 0.80). Complications were seen in 34 women (16.4%). On univariate regression, fellows did not have an impact on complications (OR 1.49, 95% CI [0.65-3.43]), which was unchanged on multivariate regression (OR 0.628, 95% CI [0.26-1.54]). Prolapse recurrence was seen in 19 women (9.5%). Fellows had no impact on prolapse recurrence (OR 0.478, 95% CI [0.17-1.38]), which was unchanged on multivariate regression (OR 0.266, 95% CI [0.17-1.49]). CONCLUSION When an expert surgeon operated together with a fellow, operative time increased by 34 min without increasing prolapse recurrence or complications.
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Outcomes after bariatric surgery according to large databases: a systematic review. Langenbecks Arch Surg 2017; 402:885-899. [PMID: 28780622 DOI: 10.1007/s00423-017-1613-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/27/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE The rapid development of technological tools to record data allows storage of enormous datasets, often termed "big data". In the USA, three large databases have been developed to store data regarding surgical outcomes: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). We aimed to evaluate the clinical impact of studies found in these databases concerning outcomes of bariatric surgery. METHODS We performed a systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines. Research carried out using the PubMed database identified 362 papers. All outcomes related to bariatric surgery were analysed. RESULTS Fifty-four studies, published between 2005 and February 2017, were included. These articles were divided into (1) outcomes related to surgical techniques (12 articles), (2) morbidity and mortality (12), (3) 30-day hospital readmission (10), (4) outcomes related to specific diseases (11), (5) training (2) and (6) socio-economic and ethnic observations in bariatric surgery (7). Forty-two papers were based on data from ACS-NSQIP, nine on data from NIS and three on data from MBSAQIP. CONCLUSIONS This review provides an overview of surgical management and outcomes of bariatric surgery in the USA. Large databases offer useful complementary information that could be considered external validation when strong evidence-based medicine data are lacking. They also allow us to evaluate infrequent situations for which randomized control trials are not feasible and add specific information that can complement the quality of surgical knowledge.
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Lodin D, Mavrothalassitis O, Haberer K, Sunderji S, Quek RGW, Peyvandi S, Moon-Grady A, Karamlou T. Revisiting the utility of technical performance scores following tetralogy of Fallot repair. J Thorac Cardiovasc Surg 2017; 154:585-595.e3. [PMID: 28461051 DOI: 10.1016/j.jtcvs.2017.02.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 01/18/2017] [Accepted: 02/08/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Although an important quality metric, current technical performance scores may not be generalizable and may omit operative factors that influence outcomes. We examined factors not included in current technical performance scores that may contribute to increased postoperative length of stay, major complications, and cost after primary repair of tetralogy of Fallot. METHODS This is a retrospective single site study of patients younger than age 2 years with tetralogy of Fallot undergoing complete repair between 2007 and 2015. Medical record data and discharge echocardiograms were reviewed to ascertain component and composite technical performance scores. Primary outcomes included postoperative length of stay, major complications, and total hospital costs. Multivariable logistic and linear regression identified determinants of each outcome. RESULTS Patient population (n = 115) had a median postoperative length of stay of 8 days (interquartile range, 6-10 days), and a median total cost of $71,147. Major complications occurred in 33 patients (29%) with 1 death. Technical performance scores assigned were optimum in 28 patients (25%), adequate in 59 patients (52%), and inadequate in 26 patients (23%). Neither technical performance score components nor composite scores were associated with increased postoperative length of stay. Optimum or adequate repairs versus inadequate had equal risk of a complication (P = .79), and equivalent mean total cost ($100,000 vs $187,000; P = .25). Longer cardiopulmonary bypass time per 1-minute increase (P < .01) was associated with longer postoperative length of stay and reintervention (P = .02). The need to return to bypass also increased total cost (P < .01). CONCLUSIONS Current tetralogy of Fallot technical performance scores were not associated with selected outcomes in our postoperative population. Although returning to bypass and bypass length are not included as components in the current score, these are important factors influencing complications and resource use in our population. Revisions anticipated from a prospective trial should consider including these variables.
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Affiliation(s)
- Daud Lodin
- San Juan Bautista School of Medicine, Caguas, Puerto Rico
| | | | - Kim Haberer
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Sherzana Sunderji
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Ruben G W Quek
- Global Health Economics, Amgen Inc, Thousand Oaks, Calif
| | - Shabnam Peyvandi
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Anita Moon-Grady
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Phoenix Children's Hospital, Phoenix, Ariz.
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Major P, Wysocki M, Dworak J, Pędziwiatr M, Małczak P, Budzyński A. Are bariatric operations performed by residents safe and efficient? Surg Obes Relat Dis 2017; 13:614-621. [DOI: 10.1016/j.soard.2016.11.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/03/2016] [Accepted: 11/19/2016] [Indexed: 01/11/2023]
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Vaidyanathan S, Samsudin A, Singh G, Hughes PL, Soni BM, Selmi F. Large subcapsular hematoma following ureteroscopic laser lithotripsy of renal calculi in a spina bifida patient: lessons we learn. Int Med Case Rep J 2016; 9:253-9. [PMID: 27601933 PMCID: PMC5003592 DOI: 10.2147/imcrj.s99960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Paraplegic patients are at greater risk of developing complications following ureteroscopic lithotripsy because of urine infection associated with neuropathic bladder, difficulties in access due to altered anatomy of urinary bladder and urethra, spinal curvature, spasticity, and contractures. We report the occurrence of large subcapsular hematoma following ureteroscopy and discuss lessons we learn from this case. Case report A 48-year-old male patient with spina bifida underwent ureteroscopy with laser lithotripsy and ureteric stenting for left ureteric stone and staghorn calculus with hydronephrosis; laser lithotripsy was repeated after 3 months; both procedures were performed by a senior urologist and did not result in any complications. Ureteroscopic laser lithotripsy was performed 5 months later by a urological trainee; it was difficult to negotiate the scope as vision became poor because of bleeding (as a result of the procedure). Postoperatively, hematuria persisted; temperature was 39°C. Cefuroxime was given intravenously followed by gentamicin for 5 days; hematuria subsided gradually; he was discharged home. Ten days later, this patient developed temperature, the urine culture grew Pseudomonas aeruginosa, and ciprofloxacin was given orally. Computed tomography (CT) of the urinary tract, performed 4 weeks after ureteroscopy, revealed a 9×7 cm subcapsular collection on the left kidney compressing underlying parenchyma. Percutaneous drainage was not feasible because of severe curvature of spine. Isotope renogram revealed deterioration in left renal function from 30% to 17%. Follow-up CT revealed reduction in the size of subcapsular hematoma, no hydronephrosis, and several residual calculi. Conclusion Risk of subcapsular hematoma following ureteroscopic lithotripsy can be reduced by avoiding prolonged endoscopy and performing ureteroscopy under low pressure. When a paraplegic patient develops features of infection after ureteroscopy, renal imaging should be carried out promptly. Extended perioperative medical care is required for spinal cord injury patients because of their propensity to develop sepsis. Antibiotics should be prescribed on the basis of recent urine microbiology results. Spinal cord injury patients should be treated by senior, experienced doctors and cared for in a spinal injuries unit in order to minimize complications.
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Affiliation(s)
| | - Azi Samsudin
- Department of Urology, Whiston Hospital, Prescot, UK
| | | | - Peter L Hughes
- Department of Radiology, Southport and Formby District General Hospital, Southport, UK
| | - Bakul M Soni
- Regional Spinal Injuries Center, Southport and Formby District General Hospital, Southport, UK
| | - Fahed Selmi
- Regional Spinal Injuries Center, Southport and Formby District General Hospital, Southport, UK
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