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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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Wityk M, Dowgiałło-Gornowicz N, Bobowicz M. Impact of Patient- and Surgeon-Related Factors on Weight Loss after Laparoscopic Sleeve Gastrectomy-A Single-Center Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1450. [PMID: 39336491 PMCID: PMC11434286 DOI: 10.3390/medicina60091450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/25/2024] [Accepted: 08/29/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: Surgical treatment for obesity is becoming increasingly popular. Surgeons have been trying to find a simple way to predict the type of surgical intervention that is best for a specific patient. This study aimed to determine the patient- and surgeon-related factors that affect weight loss after laparoscopic sleeve gastrectomy (LSG). Materials and Methods: A total of 129 patients underwent LSG in one surgical department. The following factors were analyzed: gender; age; highest preoperative and 6-month postoperative weight; the occurrence of obesity-related diseases, such as type 2 diabetes and hypertension; the number of surgeons involved in the surgery; and who performed the surgery, a resident or specialist. The outcomes also included length of hospital stay, operative time and complications. Statistical significance was defined as p ≤ 0.05. Results: A total of 129 patients (94 female) with a median age of 43 years and BMI of 43.1 kg/m2 underwent LSG, while a total of 109 (84.5%) patients achieved ≥50% of excess BMI loss (%EBMIL). Preoperative weight loss had no impact on %EBMIL (p = 0.95), operative time (p = 0.31) and length of hospital stay (p = 0.2). Two versus three surgeons in the operating team had no impact on surgery time (p = 0.1), length of stay (p = 0.98) and %EBMIL (p = 0.14). The operative time and length of hospital stay were similar for specialists and surgeons in training. %EBMIL was higher in the residents' surgery without statistical significance (p = 0.19). Complications occurred in 3.9% without mortality or leaks. Conclusions: Preoperative comorbidities, surgeons' experience and the number of surgeons in the operating team do not impact the complication rate, length of hospital stay, operative time and postoperative weight loss after LSG.
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Affiliation(s)
- Mateusz Wityk
- Department of General and Oncological Surgery, Regional Health Centre, 59-300 Lubin, Poland;
| | - Natalia Dowgiałło-Gornowicz
- Department of General, Minimally Invasive and Elderly Surgery, University of Warmia and Mazury in Olsztyn, Niepodleglosci 44 Str., 10-045 Olsztyn, Poland
| | - Maciej Bobowicz
- Department of Radiology, Medical University of Gdansk,17 Smoluchowskiego Str., 80-211 Gdansk, Poland;
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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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Matveev IA, Popov IB, Mashkin AM, Dmitriev AV, Yakhyaev EZ, Borodin NA, Khasiya DT, Matreninskikh AO. [Analysis of learning curves for mini-gastric bypass in 341 patients with obesity]. Khirurgiia (Mosk) 2024:22-29. [PMID: 39268733 DOI: 10.17116/hirurgia202409122] [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: 09/15/2024]
Abstract
OBJECTIVE To analyze learning curves and appropriate experience on the features of mini-bypass surgery in 341 obese patients. MATERIAL AND METHODS A total of 341 laparoscopic mini-gastric bypass surgeries performed by one surgeon were studied. The median age of patients was 40.5 [34; 48.3] years. There were 284 (83.2%) women and 57 (16.8%) men. The median BMI was 45 [40;52] kg/m2. RESULTS The period of MGB development consisted of 138 interventions. Surgery time was 120 [100; 130] min and 90 [82.5; 100] mins after development of this technique (p=0.001). Complications occurred in 5 (1.5%) patients (1 patient with Clavien Dindo grade IIIA and 4 ones with grade IIIB). Of these, there were 3 patients with stapler suture defects. There were no complications only in the 4th quartile of surgeries. Surgical experience significantly affects postoperative outcomes. Surgery time was more influenced by surgical skill rather technique of anastomosis imposing. CONCLUSION Polynomial regression objectively characterizes development of surgical skills lasting 138 interventions. MGB is safe for morbid obesity with a complication rate of 1.5% and no mortality.
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Affiliation(s)
- I A Matveev
- Tyumen State Medical University, Tyumen, Russia
- Regional Clinical Hospital No. 1, Tyumen, Russia
| | - I B Popov
- Tyumen State Medical University, Tyumen, Russia
- Regional Clinical Hospital No. 1, Tyumen, Russia
| | - A M Mashkin
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A V Dmitriev
- Tyumen State Medical University, Tyumen, Russia
- Regional Clinical Hospital No. 1, Tyumen, Russia
| | | | - N A Borodin
- Tyumen State Medical University, Tyumen, Russia
| | - D T Khasiya
- Tyumen State Medical University, Tyumen, Russia
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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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Wysocki M, Ciszek K, Rymarowicz J, Zarzycki P, Walędziak M, Bartosiak K, Jaworski P, Kupczyk W, Szeliga J, Tarnowski W, Pisarska-Adamczyk M, Małczak P, Pędziwiatr M, Major P. The analysis of factors increasing the odds for type 2 diabetes mellitus remission following re-do bariatric surgery after laparoscopic sleeve gastrectomy- cohort study. Langenbecks Arch Surg 2023; 408:371. [PMID: 37736842 PMCID: PMC10516768 DOI: 10.1007/s00423-023-03102-0] [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: 03/14/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Metabolic/bariatric surgery is the only proven treatment for type 2 diabetes mellitus (T2D) with curative intent. However, in a number of patients, the surgery is not effective or they may experience a relapse. Those patients can be offered re-do bariatric surgery (RBS). PURPOSE The study aimed to determine factors increasing the odds for T2D remission one year after RBS following primary laparoscopic sleeve gastrectomy. METHODS A multicenter retrospective cohort study was conducted between January 2010 and January 2020, which included 12 bariatric centers in Poland. The study population was divided into groups: Group 1- patients with T2D remission after RBS (n = 28) and Group 2- patients without T2D remission after RBS (n = 49). T2D remission was defined as HBA1c < 6.0% without glucose-lowering pharmacotherapy and glycemia within normal range at time of follow-up that was completed 12 months after RBS. RESULTS Fifty seven females and 20 males were included in the study. Patients who achieved BMI < 33 kg/m2 after RBS and those with %EBMIL > 60.7% had an increased chance of T2D remission (OR = 3.39, 95%CI = 1.28-8.95, p = 0.014 and OR = 12.48, 95%CI 2.67-58.42, p = 0.001, respectively). Time interval between primary LSG and RBS was significantly shorter in Group 1 than in Group 2 [1 (1-4) vs. 3 (2-4) years, p = 0.023]. CONCLUSIONS Shorter time interval between LSG and RBS may ease remission of T2D in case of lack of remission after primary procedure. Significant excess weight loss seems to be the most crucial factor for T2D remission.
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Affiliation(s)
- Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Karol Ciszek
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland.
| | - Justyna Rymarowicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Piotr Zarzycki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Katarzyna Bartosiak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Paweł Jaworski
- Centre of Postgraduate Medical Education, Orlowski Hospital, Warsaw, Poland
| | - Wojciech Kupczyk
- Department of General, Gastroenterological, and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Torun, Poland
| | - Jacek Szeliga
- Department of General, Gastroenterological, and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Torun, Poland
| | - Wiesław Tarnowski
- Centre of Postgraduate Medical Education, Orlowski Hospital, Warsaw, Poland
| | - Magdalena Pisarska-Adamczyk
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
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Fer D, Zhang B, Abukhalil R, Goel V, Goel B, Barker J, Kalesan B, Barragan I, Gaddis ML, Kilroy PG. An artificial intelligence model that automatically labels roux-en-Y gastric bypasses, a comparison to trained surgeon annotators. Surg Endosc 2023:10.1007/s00464-023-09870-6. [PMID: 36658282 DOI: 10.1007/s00464-023-09870-6] [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: 03/21/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Artificial intelligence (AI) can automate certain tasks to improve data collection. Models have been created to annotate the steps of Roux-en-Y Gastric Bypass (RYGB). However, model performance has not been compared with individual surgeon annotator performance. We developed a model that automatically labels RYGB steps and compares its performance to surgeons. METHODS AND PROCEDURES 545 videos (17 surgeons) of laparoscopic RYGB procedures were collected. An annotation guide (12 steps, 52 tasks) was developed. Steps were annotated by 11 surgeons. Each video was annotated by two surgeons and a third reconciled the differences. A convolutional AI model was trained to identify steps and compared with manual annotation. For modeling, we used 390 videos for training, 95 for validation, and 60 for testing. The performance comparison between AI model versus manual annotation was performed using ANOVA (Analysis of Variance) in a subset of 60 testing videos. We assessed the performance of the model at each step and poor performance was defined (F1-score < 80%). RESULTS The convolutional model identified 12 steps in the RYGB architecture. Model performance varied at each step [F1 > 90% for 7, and > 80% for 2]. The reconciled manual annotation data (F1 > 80% for > 5 steps) performed better than trainee's (F1 > 80% for 2-5 steps for 4 annotators, and < 2 steps for 4 annotators). In testing subset, certain steps had low performance, indicating potential ambiguities in surgical landmarks. Additionally, some videos were easier to annotate than others, suggesting variability. After controlling for variability, the AI algorithm was comparable to the manual (p < 0.0001). CONCLUSION AI can be used to identify surgical landmarks in RYGB comparable to the manual process. AI was more accurate to recognize some landmarks more accurately than surgeons. This technology has the potential to improve surgical training by assessing the learning curves of surgeons at scale.
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Affiliation(s)
- Danyal Fer
- University of California, San Francisco-East Bay, General Surgery, Oakland, CA, USA.,Johnson & Johnson MedTech, New Brunswick, NJ, USA
| | - Bokai Zhang
- Johnson & Johnson MedTech, New Brunswick, NJ, USA
| | - Rami Abukhalil
- Johnson & Johnson MedTech, New Brunswick, NJ, USA. .,, 5490 Great America Parkway, Santa Clara, CA, 95054, USA.
| | - Varun Goel
- University of California, San Francisco-East Bay, General Surgery, Oakland, CA, USA.,Johnson & Johnson MedTech, New Brunswick, NJ, USA
| | - Bharti Goel
- Johnson & Johnson MedTech, New Brunswick, NJ, USA
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Wysocki M, Łabul M, Małczak P, Proczko-Stepaniak M, Szymański M, Hady HR, Głuszyńska P, Myśliwiec P, Walędziak M, Zarzycki P, Rymarowicz J, Pędziwiatr M, Pisarska-Adamczyk M, Major P, Pędziwiatr M, Rymarowicz J, Zarzycki P, Stefura T, Ciszek K, Myśliwiec P, Hady HR, Głuszyńska P, Proczko-Stepaniak M, Szymański M, Walędziak M, Janik M, Kwiatkowski A, Materlak M, Bartosiak K, Czyżykowski Ł, Mawlichanów M, Kowalewski P, Szeliga J, Kupczyk W, Dowgiałło-Gornowicz N, Lech P, Harań A, Kowalski G, Łabul M, Mulek R, Kreft M, Wysocki M, Orłowski M, Franczak P, Binda A, Tarnowski W, Jaworski P, Bartosiak K, Kamiński M, Pastuszka M, Lisik W, Szymański P, Katkowski B, Leśniak M. Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter Polish Revision Obesity Surgery Study. Surg Obes Relat Dis 2023; 19:68-75. [PMID: 36182567 DOI: 10.1016/j.soard.2022.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/12/2022] [Accepted: 08/21/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The growing number of primary bariatric operations has led to an increase in demand for revision surgeries. Higher numbers of revisional operations are also observed in Poland, yet their safety and efficacy remain controversial because of a lack of current recommendations and guidelines. OBJECTIVE To review risk factors influencing perioperative morbidity. METHODS A retrospective study was conducted to analyze the results of surgical treatment among 12 Polish bariatric centers. Inclusion criteria were laparoscopic revisional bariatric surgeries and patients ≥18 years of age. The study included 795 patients, of whom 621 were female; the mean age was 47 years (range: 40-55 years). RESULTS Perioperative morbidity occurred in 92 patients (11.6%) enrolled in the study, including 76 women (82.6%). The median age was 45 years (range: 39-54 years). Statistically significant risk factors in univariate logistic regression models for perioperative complications were the duration of obesity, revisional surgery after Roux-en-Y gastric bypass (RYGB) or adjustable gastric band (AGB), difference in body mass index before revisional surgery and the lowest achieved after primary surgery, and postoperative morbidity of the primary surgery as the cause for revisional bariatric surgery. These factors were included in the multivariate regression model. Revisional surgery after AGB (odds ratio [OR] = 2.18; 95% confidence interval [CI]: 1.28-3.69; P = .004), revisional surgery performed after RYGB (OR = 6.52; 95% CI: 1.98-21.49; P = .002), and revisions due to complication of the primary surgery (OR = 1.89; 95% CI: 1.06-3.34; P = .030) remained independent risk factors for perioperative morbidity. CONCLUSION Revisional operations after RYGB or AGB and those performed because of postoperative morbidity after primary surgery as the main cause for revisional surgery were associated with a significantly increased risk of postoperative morbidity.
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Affiliation(s)
- Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Michał Łabul
- Department of General Surgery, Specialist Hospital, Legnica, Poland
| | - Piotr Małczak
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland.
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Michał Szymański
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Hady Razak Hady
- First Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Paulina Głuszyńska
- First Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Myśliwiec
- First Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Piotr Zarzycki
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Justyna Rymarowicz
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Pędziwiatr
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | | | - Piotr Major
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
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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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10
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Pisarska-Adamczyk M, Tylec P, Przytuła N, Wierzbicka J, Wysocki M, Małczak P, Budzyński P, Major P, Pędziwiatr M. Thyroidectomy: is it safe to be performed by general surgery residents? - single centre experience. Acta Chir Belg 2021; 123:266-271. [PMID: 34503400 DOI: 10.1080/00015458.2021.1979185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Thyroidectomy carries a risk of two crucial complications - recurrent nerve palsy and hypocalcaemia. The aim of the study was to assess the safety of thyroidectomy performed by general surgery residents. METHODS Data of 515 patients, who underwent total thyroidectomy between the years 2015 and 2019, were prospectively collected. Inclusion criteria were as follows: age >18 years old, patients who underwent total thyroidectomy, no change of operator during the surgery. The study group was divided into two groups: operated by general surgery specialists (385 patients-group 1) and operated by residents with the supervision of experienced general surgery specialists as assistants (130 patients-group 2). RESULTS Demographic factors did not differ statistically between groups. Median operative time was 65 min (55-85 IQR) and 90 min (75-110 IQR) in groups 1 and 2, respectively (p < 0.001). Complications occurred in 97 (18.7%) patients in group 1 and 25 (19.3%) patients in group 2 (p = 0.893). Recurrent nerve palsy diagnosed with laryngoscopy was the most common complication - 10.2% and 9.2% of patients, respectively (p = 0.754). Permanent vocal paresis occurred in 2.3% and 3.2%, respectively (p = 0.786). Postoperative symptomatic hypocalcaemia occurred in 7% of patients in group 1 and 10% of patients in group 2 (p = 0.271). Logistic regression did not show that resident as the operator with or without intraoperative neuromonitoring is a risk factor for any complications. CONCLUSION The results of the present study show that thyroidectomy performed by a general surgery resident under supervision can be as safe as the one performed by a specialist.
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Affiliation(s)
| | - Piotr Tylec
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Natalia Przytuła
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Julia Wierzbicka
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Cracow, Cracow, Poland
| | - Piotr Małczak
- Department of Medical Education, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Budzyński
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Cracow, Cracow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
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11
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Soliman MK, Tammany AJ. Teaching and Training Surgeons in Robotic Colorectal Surgery. Clin Colon Rectal Surg 2021; 34:280-285. [PMID: 34504401 DOI: 10.1055/s-0041-1729861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Robotic surgery is becoming more popular among practicing physicians as a new modality with improved visualization and mobility (1-2). As patients also desire minimally invasive procedures with quicker recoveries, there is a desire for new surgical residents and fellows to pursue robotic techniques in training (3-4). To develop a new colorectal robotics training program, an institution needs a well-formulated plan for the trainees and mentors with realistic expectations. The development of a robotics training program has potential obstacles, including increased initial cost, longer operative times, and overcoming learning curves. We have devised a four-phase training protocol for residents in colorectal surgical fellowship. Each of these phases attempts to create a curricular framework that outlines logical progression and sets expectations for trainees, Program Directors, and residency faculty. Phase zero begins prior to fellowship and is preparatory. Phase one focuses on an introduction to robotics with learning bedside console troubleshooting and simulation exercises. Phase Two prioritizes operative experience and safety while completing steps independently in a progressive fashion. Phase Three polishes the resident prior to graduation for future practice. We recommend frequent evaluation and open-mindedness while establishing a focused robotics program. The end goal is to graduate fellows with an equivalency certificate who can continue to practice colorectal robotic surgery.
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Affiliation(s)
- Mark K Soliman
- Department of Colorectal Surgery, Advent Health Digestive Health and Surgery Institute, Orlando, Florida
| | - Alison J Tammany
- Department of Colorectal Surgery, Advent Health Digestive Health and Surgery Institute, Orlando, Florida
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12
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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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13
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Is Previous Abdominal Surgery an Obstacle to Laparoscopic Bariatric Surgery? Indian J Surg 2021. [DOI: 10.1007/s12262-021-02981-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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14
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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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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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Analysis of the learning process for laparoscopic sleeve gastrectomy: CUSUM-curve of 110 consecutive patients with 1-year follow-up. J Visc Surg 2020; 158:198-203. [PMID: 32446913 DOI: 10.1016/j.jviscsurg.2020.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure worldwide. A tremendous recent increase in the number of LSGs has not been driven by an accurate learning process, especially in low volume bariatric centers. The cumulative-sum (CUSUM) method is an effective analysis of the learning process, taking intraoperative and postoperative variables into account. This study was aimed at establishing a CUSUM learning curve for LSG in order to define the number of procedures needed to achieve sufficient surgical skill. METHODS All LSGs performed by a single general surgeon between September 2014 and November 2017 were considered. We hypothesized that the key t variables related to the LSG learning process (LP) are: operative time (OT), intraoperative complications or difficulties, need for expert assistance, length of hospital stay (LOS), and 3-month postoperative morbidity. All of these parameters are binary variables analyzed with the risk-adjusted CUSUM method. Two groups, learning group (LG) and experienced group (EG), were identified and compared by univariate analysis. Multivariate analysis was performed to identify the variables most closely associated with operative time and surgical success. One-year weight loss outcomes were likewise analyzed. RESULTS One hundred and ten (110) consecutive LSGs were considered. CUSUM-LSG showed that the mean number of consecutive interventions necessary to reach proficiency in LSG was 58. In multivariate analysis, surgical success was negatively correlated with longer operative time and need for expert assistance. Body mass index was not correlated with surgical success. CONCLUSION Fifty-eight LSG procedures were required to achieve surgical skill. Operative time and the need for expert assistance were variables most closely associated with surgical success. ACGME COMPETENCY Practice-based learning and improvement.
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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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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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Sibia US, Turcotte JJ, Klune JR, Feather CB. How Does a New General Surgery Residency Program's Junior Residents Impact Hospital Efficiency and Productivity? JOURNAL OF SURGICAL EDUCATION 2020; 77:309-315. [PMID: 31889692 DOI: 10.1016/j.jsurg.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/21/2019] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The general surgery workforce deficit is projected to grow to 15% to 21% by 2050. An estimated 6.6% increase to existing general surgery residency (GSR) programs is needed to meet this shortfall. The purpose of this study was to examine the impact of a new GSR program on efficiency and productivity at a regional healthcare center. STUDY DESIGN An institutional database was retrospectively queried for all GSR related procedures between July 2015 and June 2018. Procedures done prior to GSR initiation (pre-GSR) were compared to those done after (post-GSR). Univariate and multivariate analyses were performed. RESULTS We reviewed 10,617 procedures (6365 pre-GSR vs. 4252 post-GSR). Patients had lower preoperative Hierarchical Condition Category scores in the post-GSR group (0.71 vs. 0.58, p < 0.01). Operative times increased post-GSR (101.7 vs. 109.1 minutes, p < 0.01), but length of stay decreased (6.4 vs. 5.5 days, p = 0.01). Thirty-day readmissions (4.0% vs. 3.4%, p = 0.11) were comparable, but reoperations significantly decreased post-GSR (10.1% vs. 8.6%, p = 0.01). Average hospital costs remained unchanged ($10,765 vs. $10,140, p = 0.12). Multivariate analysis revealed no statistical difference in operative times, length of stay, 30-day readmissions and reoperations, and hospital costs between the 2 groups. Subset analysis based on surgical service also showed no statistical difference. Productivity increased on the general surgery service post-GSR (7.1 vs. 7.8 cases per day, p = 0.02). Patient satisfaction increased post-GSR (76% vs. 81%, p = 0.31), but without statistical significance. CONCLUSION The initiation of a new GSR program did not negatively impact operative times, length of stay, 30-day readmissions and reoperations, hospital costs, case volume, or patient satisfaction.
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Affiliation(s)
- Udai S Sibia
- Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland.
| | - Justin J Turcotte
- Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland
| | - John R Klune
- Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland
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The Influence of Surgical Experience on Postoperative Recovery in Fast-Track Bariatric Surgery. Obes Surg 2020; 30:1653-1659. [PMID: 31965487 DOI: 10.1007/s11695-020-04399-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Short duration of surgery is an important aspect in fast-track protocols. Peroperative training of surgical residents could influence the duration of surgery, possibly affecting patient outcome. This study evaluates the influence of the operator's level of experience on patient outcome in fast-track bariatric surgery. METHODS Data was analyzed of all patients who underwent a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2004 and July 2018. Residents were trained according to a stepwise training program. For each operator, learning curves of both procedures were created by dividing the procedures in time-subsequent groups (TSGs). Data was also analyzed by comparing "beginners" with "experienced operators," with a cut-off point at 100 procedures. Primary outcome measure was duration of surgery. Secondary outcome measures were length of hospital stay (LOS), complications, and readmission rate within 30 days postoperatively. RESULTS There were 4901 primary procedures (53.1% LSG) performed by seven surgeons or surgical residents. We found no difference between beginning and experienced operators in complications or readmissions rates. The experience of the operator did not influence LOS (p = 0.201). Comparing each new operator with previous operator(s), the starting point in terms of duration of surgery was shorter, and the learning curve was steeper. The duration of surgery was significantly longer for supervised beginning operators as compared with experienced operators. CONCLUSION Within the stepwise training program for residents, there is a slight increase in duration of surgery in the beginning of the learning curve, without affecting the patient outcome.
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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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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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Inaba CS, Koh CY, Sujatha-Bhaskar S, Gallagher S, Chen Y, Nguyen NT. Operative time as a marker of quality in bariatric surgery. Surg Obes Relat Dis 2019; 15:1113-1120. [DOI: 10.1016/j.soard.2019.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/16/2019] [Accepted: 04/06/2019] [Indexed: 12/29/2022]
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Major P, Stefura T, Walędziak M, Janik M, Pędziwiatr M, Wysocki M, Rubinkiewicz M, Witowski J, Szeliga J, Budzyński A. What Makes Bariatric Operations Difficult-Results of a National Survey. ACTA ACUST UNITED AC 2019; 55:medicina55060218. [PMID: 31141961 PMCID: PMC6631593 DOI: 10.3390/medicina55060218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 05/23/2019] [Indexed: 01/12/2023]
Abstract
Background and objective: The most commonly performed bariatric procedures include laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and one anastomosis gastric bypass-mini gastric bypass (OAGB-MGB). A study comparing the degree of difficulty among those procedures could serve as a guide for decision making in bariatric surgery and further improve training programs for general surgery trainees. The aim of this study was to compare the subjective level of technical difficulty of LSG, LRYGB, and OAGB-MGB as perceived by surgeons and surgical residents. Materials and Methods: An anonymous internet-based survey was designed to evaluate the subjective opinions of surgeons and surgical residents in training in Poland. It covered baseline characteristics of the participants, difficulty of LSG, OAGB-MGB, LRYGB and particular stages of each operation assessed on a 1-5 scale. Results: Overall, 70 surgeons and residents participated in our survey. The mean difficulty degree of LSG was 2.34 ± 0.89. The reinforcing staple line with sutures was considered most difficult stage of this operation (3.17 ± 1.19). The LRYGB operation had an average difficulty level of 3.87 ± 1.04. Creation of the gastrojejunostomy was considered the most difficult stage of LRYGB with a mean difficulty level (3.68 ± 1.16). Responders to our survey assessed the mean degree of difficulty of OAGB-MGB as 2.34 ± 0.97. According to participating surgeons, creating the gastrojejunostomy is the most difficult phase of this operation (3.68 ± 1.16). Conclusion: The LSG is perceived by surgeons as a relatively easy operation. The LRYGB was considered to be the most technically challenging procedure in our survey. Operative stages, which require intra-abdominal suturing with laparoscopic instruments, seem to be the most difficult phases of each operation.
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Affiliation(s)
- Piotr Major
- nd Department of General Surgery, Jagiellonian University Medical College, 31-501 Krakow, Poland.
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), 31-501 Krakow, Poland.
| | - Tomasz Stefura
- Students' Scientific Group at 2nd Department of General Surgery, Jagiellonian University Medical College, 31-501 Krakow, Poland.
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, 04-141 Warsaw, Poland.
| | - Michał Janik
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, 04-141 Warsaw, Poland.
| | - Michał Pędziwiatr
- nd Department of General Surgery, Jagiellonian University Medical College, 31-501 Krakow, Poland.
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), 31-501 Krakow, Poland.
| | - Michał Wysocki
- nd Department of General Surgery, Jagiellonian University Medical College, 31-501 Krakow, Poland.
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), 31-501 Krakow, Poland.
| | - Mateusz Rubinkiewicz
- nd Department of General Surgery, Jagiellonian University Medical College, 31-501 Krakow, Poland.
| | - Jan Witowski
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), 31-501 Krakow, Poland.
- Students' Scientific Group at 2nd Department of General Surgery, Jagiellonian University Medical College, 31-501 Krakow, Poland.
| | - Jacek Szeliga
- Department of General, Gastroenterological, and Oncological Surgery Collegium Medicum, Nicolaus Copernicus University, 87-100 Torun, Poland.
| | - Andrzej Budzyński
- nd Department of General Surgery, Jagiellonian University Medical College, 31-501 Krakow, Poland.
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), 31-501 Krakow, Poland.
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Major P, Droś J, Kacprzyk A, Pędziwiatr M, Małczak P, Wysocki M, Janik M, Walędziak M, Paśnik K, Hady HR, Dadan J, Proczko-Stepaniak M, Kaska Ł, Lech P, Michalik M, Duchnik M, Kaseja K, Pastuszka M, Stepuch P, Budzyński A. Does previous abdominal surgery affect the course and outcomes of laparoscopic bariatric surgery? Surg Obes Relat Dis 2018; 14:997-1004. [PMID: 29801774 DOI: 10.1016/j.soard.2018.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 03/07/2018] [Accepted: 03/21/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Global experiences in general surgery suggest that previous abdominal surgery may negatively influence different aspects of perioperative care. As the incidence of bariatric procedures has recently increased, it is essential to assess such correlations in bariatric surgery. OBJECTIVES To assess whether previous abdominal surgery influences the course and outcomes of laparoscopic bariatric surgery. SETTING Seven referral bariatric centers in Poland. METHODS We conducted a retrospective analysis of 2413 patients; 1706 patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) matched the inclusion criteria. Patients with no history of abdominal surgery were included as group 1, while those who had undergone at least 1 abdominal surgery were included as group 2. RESULTS Group 2 had a significantly prolonged median operation time for RYGB (P = .012), and the longest operation time was observed in patients who had previously undergone surgeries in both the upper and lower abdomen (P = .002). Such a correlation was not found in SG cases (P = .396). Groups 1 and 2 had similar rates of intraoperative adverse events and postoperative complications (P = .562 and P = .466, respectively). Group 2 had a longer median duration of hospitalization than group 1 (P = .034), while the readmission rate was similar between groups (P = .079). There was no significant difference between groups regarding the influence of the long-term effects of bariatric treatment on weight loss (percentage of follow-up was 55%). CONCLUSIONS Previous abdominal surgery prolongs the operative time of RYGB and the duration of postoperative hospitalization, but does not affect the long-term outcomes of bariatric treatment.
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Affiliation(s)
- Piotr Major
- Second Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland.
| | - Jakub Droś
- Students' Scientific Group at the Second Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Artur Kacprzyk
- Students' Scientific Group at the Second Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Michał Pędziwiatr
- Second Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Małczak
- Second Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Wysocki
- Second Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Janik
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Krzysztof Paśnik
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Hady Razak Hady
- First Clinical Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Jacek Dadan
- First Clinical Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Łukasz Kaska
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Paweł Lech
- Chair and Clinic of General, Minimally Invasive and Elderly Surgery, University of Warmia & Mazury, Olsztyn, Poland
| | - Maciej Michalik
- Chair and Clinic of General, Minimally Invasive and Elderly Surgery, University of Warmia & Mazury, Olsztyn, Poland
| | - Michał Duchnik
- Department of General and Vascular Surgery, Individual Public Voivodeship Joint Hospital, Szczecin, Poland
| | - Krzysztof Kaseja
- Department of General and Vascular Surgery, Individual Public Voivodeship Joint Hospital, Szczecin, Poland
| | - Maciej Pastuszka
- Department of General and Minimally Invasive Surgery, Łęczna, Poland
| | - Paweł Stepuch
- Department of General and Minimally Invasive Surgery, Łęczna, Poland
| | - Andrzej Budzyński
- Second Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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Radkowiak D, Zychowicz A, Lasek A, Wysocki M, Major P, Pędziwiatr M, Budzyński P, Kulawik J, Budzyński A. 20 years' experience with laparoscopic splenectomy. Single center outcomes of a cohort study of 500 cases. Int J Surg 2018; 52:285-292. [PMID: 29481990 DOI: 10.1016/j.ijsu.2018.02.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/18/2018] [Accepted: 02/14/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Laparoscopic splenectomy (LS) has become the gold standard in elective spleen surgery. Although it is considered relatively safe, treatment results vary depending on a hospital's profile and the experience of the surgeon and center. We would like to present experience of a high-volume referral center with minimally invasive operations of the spleen. MATERIAL AND METHODS The retrospective cohort study included consecutive patients undergoing laparoscopic splenectomy in tertiary referral surgical center in 1998-2017. The entire study population (500 patients) was grouped into 5 cohorts of 100 consecutively operated patients. The primary endpoints were short-term outcomes of LS and secondary - analysis of indications and operative technique. The study group consisted of 316 women and 184 men, 46 (28-59) years old on average. RESULTS The most common indications for splenectomy were ITP (53%), lymphoma (21%) and spherocytosis (7%). Ratio of ITP versus other indications decreased significantly over time in favor of more difficult cases (<0.001). Average operative time of 100 (75-132.5) min and blood loss of 50 (20-150) ml were changing during study. Forty two patients required a blood transfusion with no difference among groups (p = 0.765). The use of postoperative drainage diminished from 100% to 7% (p < 0.001). The overall conversion rate (3%) and intraoperative complications (5%) did not differ among groups (p = 0.863 and 0.888). Perioperative morbidity was 8.6% and decreased significantly over time (OR: 0.78, 95%CI: 0.62-0.98). We noted mortality of 0.4% (1 patient in 1st and 1 in 5th group). Median LOS was 4 (1-16) days. A significant change in the operative technique from vessels first to hilar transection was noted. CONCLUSION Laparoscopic splenectomy seems to be a safe method associated with a low risk of perioperative complications and mortality. A careful reproducible operative technique, along with a well-trained team and standardized modern postoperative care is critical to improving outcomes.
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Affiliation(s)
- Dorota Radkowiak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.
| | - Anna Zychowicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.
| | - Anna Lasek
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.
| | - Michał Wysocki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Piotr Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.
| | - Jan Kulawik
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
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Inaba CS, Koh CY, Sujatha-Bhaskar S, Lee Y, Pejcinovska M, Nguyen NT. The effect of hospital teaching status on outcomes in bariatric surgery. Surg Obes Relat Dis 2017; 13:1723-1727. [PMID: 28867305 PMCID: PMC6281390 DOI: 10.1016/j.soard.2017.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/23/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Studies have shown conflicting effects of resident involvement on outcomes after laparoscopic bariatric surgery. Resident involvement may be a proxy for a teaching environment in which multiple factors affect patient outcomes. However, no study has examined outcomes of laparoscopic bariatric surgery based on hospital teaching status. OBJECTIVE To compare outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) between teaching hospitals (THs) and nonteaching hospitals (NTHs). SETTING Retrospective review of a national database in the United States. METHODS The Nationwide Inpatient Sample database (2011-2013) was reviewed for obese patients who underwent LRYGB or LSG. Patient demographic characteristics and outcomes were analyzed according to hospital teaching status. Primary outcome measures included risk-adjusted inpatient mortality and serious morbidity. RESULTS We analyzed 32,449 LRYGBs and 26,075 LSGs. There were 35,160 (60.1%) cases performed at THs and 23,364 (39.9%) cases performed at NTHs. At THs, the distribution of LRYGB versus LSG cases was 20,461 (58.2%) versus 14,699 (41.8%), respectively; at NTHs, the distribution was 11,988 (51.3%) versus 11,376 (48.7%), respectively. For LRYGB, there were no significant differences between THs versus NTHs in mortality (AOR 1.14; P = 0.99), but there was an increase in odds of serious morbidity at THs (AOR 1.36; P<0.001). For LSG, there were no significant differences between THs versus NTHs for mortality (AOR 1.15; P = 0.99) or serious morbidity (AOR 1.03; P = 0.99). CONCLUSIONS There is an association between THs and increased serious morbidity for LRYGB, but hospital teaching status has no effect on morbidity or mortality after LSG. Further research is warranted to elucidate the reasons for these associations.
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Affiliation(s)
- Colette S Inaba
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Christina Y Koh
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Sarath Sujatha-Bhaskar
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Yoon Lee
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Marija Pejcinovska
- Center for Statistical Consulting, University of California at Irvine, Irvine, California
| | - Ninh T Nguyen
- Department of Surgery, University of California Irvine Medical Center, Orange, California.
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Discussion: Nonsurgical Facial Rejuvenation-Outcomes and Safety of Neuromodulator and Soft-Tissue Filler Procedures Performed in a Resident Cosmetic Clinic. Aesthetic Plast Surg 2017. [PMID: 28643010 DOI: 10.1007/s00266-017-0913-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bolger JC, Broe MP, Zarog MA, Looney A, McKevitt K, Walsh D, Giri S, Peirce C, Coffey JC. Initial experience with a dual-console robotic-assisted platform for training in colorectal surgery. Tech Coloproctol 2017; 21:721-727. [PMID: 28929257 DOI: 10.1007/s10151-017-1687-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/18/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Minimally invasive surgery is associated with several patient-related benefits, including reduced length of hospital stay and reduced blood loss. Robotic-assisted surgery offers many advantages when compared with standard laparoscopic procedures, including a stable three-dimensional binocular camera platform, motion smoothing and motion scaling, improved dexterity and ergonomics. There are limited data on the effectiveness of the dual-console DaVinci Xi platform for teaching resident surgeons. The goal of this study was to examine preliminary outcomes following the introduction of a dual-console robotic platform in our institution. METHODS A retrospective review of our prospectively maintained patient database was performed. The first ten dual-console resident-performed procedures in colorectal surgery were compared with matched cases performed on a single console by the trainer. Patient demographics, operative times and patient outcomes were compared. RESULTS Twenty patients were included in this study. There was no significant difference in console time (p = 0.46) or total operative time (p = 0.52) when residents and trainers were compared. Patient outcomes were equivalent, with no difference in length of stay, morbidity or mortality. CONCLUSIONS The DaVinci Xi dual-console platform is a safe and effective platform for training junior surgeons. The dual-console system has the potential to alter surgical training pathways.
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Affiliation(s)
- J C Bolger
- Department of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland
| | - M P Broe
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - M A Zarog
- Department of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland
| | - A Looney
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - K McKevitt
- Department of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland
| | - D Walsh
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - S Giri
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - C Peirce
- Department of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland
| | - J C Coffey
- Department of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland. .,Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
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