Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center

BACKGROUND

Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized.

OBJECTIVES

To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles.

SETTING

Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital.

METHODS

We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology.

RESULTS

A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed.

CONCLUSIONS

Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.

Does the use of a suction calibration system (SCS) reduce stapler load firings and operative time? A randomized controlled trial comparing use of endoscopic calibration vs. SCS in laparoscopic sleeve gastrectomy

BACKGROUND

It is critical to ensure appropriate and consistent sleeve size and orientation during laparoscopic sleeve gastrectomy (LSG). Various devices are used to achieve this, including weighted rubber bougies, esophagogastroduodenoscopy (EGD), and suction calibration systems (SCS). Prior reports suggest that SCSs may decrease operative time and stapler load firings but are limited by single-surgeon experience and retrospective design. We performed the first randomized controlled trial comparing SCS against EGD in patients undergoing LSG to investigate whether the SCS decreases the number of stapler load firings.

METHODS

This was a randomized, non-blinded study from a single MBSAQIP-accredited academic center. Appropriate LSG candidates ≥ 18 years of age were randomized to EGD or SCS calibration. Exclusion criteria included prior gastric or bariatric surgery, detection of hiatal hernia before surgery, and intraoperative hiatal hernia repair. A randomized block design was employed controlling for body mass index, gender, and race. Seven surgeons employed a standardized LSG operative technique. The primary endpoint was the number of stapler load firings. Secondary endpoints were operative duration, reflux symptoms, and change in total body weight (TBW). Endpoints were analyzed via t-test.

RESULTS

A total of 125 LSG patients (84% female) underwent study enrollment, with an average age of 44 ± 12 years and average BMI of 49 ± 8 kg/m2. Overall, 117 patients were randomized to receive EGD (n = 59) or SCS (n = 58) calibration. No significant differences in baseline characteristics were identified. The mean number of stapler load firings for EGD and SCS groups were 5.43 ± 0.89 and 5.31 ± 0.81, respectively (p = 0.463). The mean operative times for EGD and SCS groups were 94.4 ± 36.5 and 93.1 ± 27.9 min, respectively (p = 0.83). There were no significant differences in post-operative reflux, TBW loss, or complications.

CONCLUSION

Use of EGD and SCS resulted in a similar number of LSG stapler load firings and operative duration. Additional research is needed to compare LSG calibration devices in different patients and settings to optimize surgical technique.

Lessons learned during the COVID-19 pandemic using virtual basic laparoscopic training in Santa Cruz de la Sierra, Bolivia: effects on confidence, knowledge, and skill

BACKGROUND

An international surgical team implemented a virtual basic laparoscopic surgery course for Bolivian general and pediatric surgeons and residents during the COVID-19 pandemic. This simulation course aimed to enhance training in a lower-resource environment despite the challenges of decreased operative volume and lack of in-person instruction.

METHODS

The course was developed by surgeons from Bolivian and U.S.-based institutions and offered twice between July-December 2020. Didactic content and skill techniques were taught via weekly live videoconferences. Additional mentorship was provided through small group sessions. Participants were evaluated by pre- and post-course tests of didactic content as well as by video task review.

RESULTS

Of the 24 enrolled participants, 13 were practicing surgeons and 10 were surgery residents (one unspecified). Fifty percent (n = 12) indicated "almost never" performing laparoscopic surgeries pre-course. Confidence significantly increased for five laparoscopic tasks. Test scores also increased significantly (68.2% ± 12.5%, n = 21; vs 76.6% ± 12.6%, n = 19; p = 0.040). While challenges impeded objective evaluation for the first course iteration, adjustments permitted video scoring in the second iteration. This group demonstrated significant improvements in precision cutting (11.6% ± 16.7%, n = 9; vs 62.5% ± 18.6%, n = 6; p < 0.001), intracorporeal knot tying (36.4% ± 38.1%, n = 9; vs 79.2% ± 17.2%, n = 7; p = 0.012), and combined skill (40.3% ± 17.7%; n = 8 vs 77.2% ± 13.6%, n = 4; p = 0.042). Collectively, combined skill scores improved by 66.3% ± 10.4%.

CONCLUSION

Virtual international collaboration can improve confidence, knowledge, and basic laparoscopic skills, even in resource-limited settings during a global pandemic. Future efforts should focus on standardizing resources for participants and enhancing access to live feedback resources between classes.

The case of the missing appendix: a case report of appendiceal intussusception at the site of colonic mullerianosis

Right lower quadrant pain is a symptom with an exceptionally broad differential diagnosis. Intussusception of the appendix is a very uncommon condition with many manifestations. Additionally, the pathologic finding of ectopic presence of a mixture of at least two mullerian-derived tissue components is rare. This report presents the case of a 49-year-old woman who presented twice with acute right lower abdominal pain. Diagnosis of appendiceal inversion was made surgically. Pathologic examination of the specimen identified extensive endometriosis, endosalpingiosis and endocervicosis of the colon wall. Appendiceal intussusception and colonic mullerianosis, present together, are discussed, and recommendations for the diagnosis and treatment of appendiceal intussusception are discussed.