Collateral Benefit of Systematic Improvement in Bariatric Surgery Outcomes Following a Single Quality Improvement Project for Bleeding

The study's aim was not only to use quality improvement system techniques to improve patient care specifically for bleeding but also to track other adverse outcomes. Key drivers were identified and mapped to interventions, namely venous thromboembolism prophylaxis, root cause analysis, indications conference, and operative technique standardization. Bleeding was reduced by 88%, and overall postoperative complications also fell by 63%. A targeted quality improvement project not only was effective in improving outcomes for the specific aim of bleeding but also resulted in improvement for other patient outcomes.

Two-Port Laparoscopic Cholecystectomy: 18 Patients Human Experience Using the Dynamic Laparoscopic NovaTract Retractor

OBJECTIVE

The concept of reducing the number of transabdominal access ports has been criticized for violating basic tenets of traditional multiport laparoscopy. Potential benefits of reduced port surgery may include decreased pain, improved cosmesis, less hernia formation, and fewer wound complications. However, technical challenges associated with these access methods have not been adequately addressed by advancement in instrumentations. We describe our initial experience with the NovaTract™ Laparoscopic Dynamic Retractor.

METHODS

A retrospective review of all patients who underwent two-port laparoscopic cholecystectomy between 2013 and 2014 using the NovaTract retractor was performed. The patients were equally divided into three groups (Group A, B, C) based on the order of case performed.

RESULTS

Eighteen consecutive patients underwent successful two-port laparoscopic cholecystectomy for symptomatic cholelithiasis. Mean age was 39.9 years and mean body mass index was 28.1 kg/m(2) (range 21-39.4). Overall mean operative time was 65 minutes (range 42-105), with Group A of 70 minutes, Group B of 65 minutes, and Group C of 58 minutes (P = .58). All cases were completed laparoscopically using the retraction system, without a need for additional ports or open conversion. No intra- or postoperative complications were seen. All patients were discharged on the same day of surgery. No mortality found in this series.

CONCLUSIONS

The NovaTract laparoscopic dynamic retractor is safe and easy to use, which is reflected by acceptable operative time for a laparoscopic cholecystectomy using only two ports. The system allows surgical approach to mimic the conventional laparoscopic techniques, while eliminating or reducing the number of retraction ports.

The influence of surgeon personality factors on risk tolerance: a pilot study

OBJECTIVE

This study attempts to assess the association between surgeon personality factors (measured by the Myers-Briggs Type Indicator personality inventory (MBTI(®))) and risk tolerance (measured by the Revised Physicians' Reactions to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales).

DESIGN

Instrument assessing surgeon personality profile (MBTI) and 2 questionnaires measuring surgeon risk tolerance and risk aversion (PRU and PRA).

SETTING

Saint Raphael campus of Yale New Haven Hospital in New Haven, Connecticut.

PARTICIPANTS

Twenty categorical surgery residents and 7 surgical core faculty members.

RESULTS

The following findings suggest there might be a relationship between surgeon personality factors and risk tolerance.

CONCLUSIONS

In certain areas of risk assessment, it appears that surgeons with personality factors E (Extravert), T (Thinking), and P (Perception) demonstrated higher tolerance for risk. Conversely, as MBTI(®) dichotomies are complementary, surgeons with personality factors I (Introvert), F (Feeling), and J (Judgment) suggest risk aversion on these same measures. These findings are supported by at least 2 studies outside medicine demonstrating that personality factors E, N, T, and P are associated with risk taking. This preliminary research project represents an initial step in exploring what may be considered a fundamental component in a "successful" surgical personality.

Magenstrasse and Mill gastroplasty and sleeve gastrectomy as treatment for morbid obesity

BACKGROUND

Laparoscopic nonbanded restrictive procedures are becoming more popular as staging and primary operations in bariatric surgery. The Magenstrasse and Mill (MM) procedure produces a restrictive gastric tubular pouch based along the lesser curvature; for the most part anatomy and physiology are preserved. In Sleeve Gastrectomy (SG), 80% of normal stomach is resected to produce restriction and to decrease ghrelin levels.

METHODS

This is a retrospective nonrandomized study evaluating the medical records of patients who had the laparoscopic MM (LMM) and laparoscopic SG (LSG) between January 2007 and October 2008. One bariatric surgeon performed the LMM and two bariatric surgeons performed the LSG.

RESULTS

A total of 20 patients were identified: 13 SG and 7 MM. The mean age was 50 for the MM vs 42.9 for the SG. For the MM, the mean preoperative body mass index (BMI) was 65.4 +/- 11.1 kg/m2, with a mean excess weight of 282 +/- 73.7 kg. For the SG, the mean preoperative body mass index was 47.5 +/- 8.3 kg/m2, with a mean excess weight of 156.1 +/- 52.6 kg. The mean excess weight loss after six and 12 months for the M&M was 35 +/- 10.5% and 20.1 +/- 1.4%, vs 52.4 +/- 17.8% and 49% +/- 15.4% for the SG. Follow-up of one year was achieved in two M&M patients and three SG patients. Median follow-up of all patients was seven months (range 12-1).

CONCLUSION

This is a short-term retrospective outcome study. The LMM patients were larger than LSG patients. Total weight loss was greater for the LMM patients. Operative time for the LMM is shorter. The percent excess weight loss in the short-term 12 month period was more in the LSG compared to the LMM. Long-term follow-up is needed.

The impact of laparoscopy on the volume of open cases in general surgery training

OBJECTIVE

The purpose of this study was to evaluate the impact of laparoscopy on the volume of open cases in general surgery residency training over the past 10 years.

DESIGN

The Accreditation Council for Graduate Medical Education (ACGME) database (1999-2008), which records all cases (by Current Procedural Terminology code) performed by graduating general surgery trainees, was retrospectively analyzed.

SETTING

ACGME database (1999-2008).

MAIN OUTCOME MEASURES

Trends were compared regarding the average number of the most common laparoscopic and open procedures (colectomy, hernia, and appendectomy) performed by graduating general surgery trainees during the reporting period.

RESULTS

Across all procedures, an increase was noted in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7 to 21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5 to 32.1). Similarly, open inguinal hernia cases decreased by 12.5% (51.9 to 45.4) and open colectomy cases decreased by 10.4% (48 to 43). Conversely, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6 to 15.8) and 550% (2 to 13), respectively.

CONCLUSIONS

In addition to the limitations placed on residency training by other factors (including work hour restrictions), changing practice patterns within the field of general surgery have a significant impact on the exposure of residents to open surgery cases. This trend might have far-reaching implications with regard to the overall competency of graduating residents and raises concerns for the future direction of surgical education.

Clinical pulmonary embolus after gastric bypass surgery

BACKGROUND

Pulmonary embolus (PE) is one of the most common causes of death for patients undergoing gastric bypass surgery. The risk of developing PE has been associated with increased age, greater body mass index (BMI), and chronic venous stasis disease.

METHODS

Between 1998 and 2003, 1225 patients underwent open Roux-en-Y gastric bypass (RYGBP) surgery (258 men and 967 women) for the treatment of morbid obesity and its related disorders. The medical records for morbidly obese patients diagnosed with PE after RYGBP were identified. The presenting signs and symptoms were reviewed, and the known risk factors were analyzed. We compared the age and BMI of these patients with those of a randomly selected RYGBP control group. The Mann-Whitney U test was used to analyze the statistical significance of the results.

RESULTS

During the study period, 11 patients were diagnosed with PE (0.9%). Six patients were men and five were women, for a gender-specific incidence of PE of 2.3% in men and 0.5% in women. The average BMI was 62.5 kg/m(2) in the men and 59.1 kg/m(2) in the women, much greater than in the control group (men 53 kg/m(2) and women 52 kg/m(2); P <0.005 and P <0.05, respectively). All male patients were super-obese (BMI >50 kg/m(2)). The total number of super-obese patients undergoing RYGBP during the study period was 147, for an incidence of PE in super-obese men of 4%. Nine of the 11 patients developed PE after discharge from the hospital within an average of 10 days.

CONCLUSION

The super-obese male patient is at a much greater risk of developing PE than other RYGBP patients (relative risk 4.4). The risk extends to several weeks after discharge. Therefore, extending PE prophylaxis to several weeks after surgery may be warranted.

A comparison of pediatric and adult trauma patients transported by helicopter and ground EMS: managed-care considerations

INTRODUCTION

There is a paucity of data comparing injured pediatric patients transported by helicopter emergency medical services (HEMS) with patients transported by ground ambulance. The purpose of this study was to compare HEMS pediatric trauma patients to: 1) pediatric patients transported by ground to an urban level-1 trauma center (TC), and; 2) a similar cohort of adult patients. The managed-care consequences of these comparisons are highlighted.

METHODS

All trauma patients flown directly from the scene by HEMS from January 1, 1990, to April 30, 1993, were compared to a cohort of trauma patients arriving by ground advanced life support (ALS). All patients were transported to the same level-1 TC. The data collected included the mechanism of injury and the prehospital procedures performed, the injury severity score (ISS), and outcome.

RESULTS

There was no difference in the ISS between the HEMS (n = 216) and ground ALS (n = 355) pediatric patients (16.8 vs 17.1; p = 0.55). Adult HEMS patients (n = 202) had significantly higher ISS than did injured adults (n = 1652) transported by ground (18.0 vs 13.6; p < 0.0001). Overall, trauma patients transported by air directly from the scene have a higher ISS than patients transported by ground (17.5 vs 13.6; p < 0.001).

CONCLUSIONS

Pediatric patients transported by HEMS were as severely injured as those transported by ground, in contrast to adult patients. We conjecture that since trauma triage schemes classically focus on adults, ground personnel are more selective about which patients are flown to a TC, and less selective for pediatric patients. Trauma centers and HEMS programs should develop pediatric trauma triage protocols that do not overemphasize physiologic parameters.