Updates in Bariatric Surgery

Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.

Predicting readmission after bariatric surgery using machine learning

BACKGROUND

While bariatric surgery is an effective method for achieving long-term weight loss, postoperative readmissions are associated with negative clinical outcomes and significant costs.

OBJECTIVES

We aimed to use machine learning (ML) algorithms to predict readmissions and compare results to logistic regression.

SETTING

Hospitals participating in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, United States.

METHODS

Patients who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch between 2016 and 2020 were selected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Patient variables reported by the MBSAQIP database were analyzed by ML algorithms random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and the results of the predictive models were compared to logistic regression using area under the receiver operating characteristic curve (AUROC).

RESULTS

Our study included 863,348 patients, of which 39,068 (4.52%) were readmitted. AUROC scores were XGB .785 (95% CI .784-.786), RF .785 (95% CI .784-.785), and NN .754 (95% CI .753-.754), compared with .62 (95% CI .62-.621) for logistic regression (LR) (P < .001). The sensitivity and specificity for XGB, the best performing model, were 73.81% and 70%, compared with 52.94% and 70% for logistic regression. The most important variables were intervention or reoperation prior to discharge, unplanned ICU admission, initial procedure, and the intraoperative transfusion.

CONCLUSIONS

ML demonstrates significant advantages over logistic regression when predicting 30-day readmission following bariatric surgery. With external validation, models could identify the best candidates for early discharge or targeted postdischarge resources.

Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: A Single-Institution Report

Laparoscopic sleeve gastrectomy (LSG) is an effective weight-loss operation. Portomesenteric vein thrombosis (PMVT) is an important complication of LSG. We identified four cases of PMVT after LSG at our institution in women aged 36-47 with BMIs ranging from 44-48 kg/m2. All presented 8-19 days postoperatively. Common symptoms were nausea, vomiting, and abdominal pain. Thrombotic risk factors were previous deep vein thrombosis and oral contraceptive use. Management included therapeutic anti-coagulation, directed thrombolysis, and surgery. Complications were readmission, bowel resection, and bleeding. Discharge recommendations ranged from 3-6 months of anticoagulation using various anticoagulants. No consensus was reached on post-treatment hypercoagulable work up or imaging. All cases required multi-disciplinary approach with Surgery, Interventional Radiology, and Hematology. As PMVT is a rare but potentially morbid complication of LSG, further development of tools that quantify preoperative thrombotic risk and clear guidance regarding use of anticoagulants are needed for prevention and treatment of PMVT following LSG.

Application of machine learning to predict postoperative gastrointestinal bleed in bariatric surgery

BACKGROUND

Postoperative gastrointestinal bleeding (GIB) is a rare but serious complication of bariatric surgery. The recent rise in extended venous thromboembolism regimens as well as outpatient bariatric surgery may increase the risk of postoperative GIB or lead to delay in diagnosis. This study seeks to use machine learning (ML) to create a model that predicts postoperative GIB to aid surgeon decision-making and improve patient counseling for postoperative bleeds.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to train and validate three types of ML methods: random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and compare them with logistic regression (LR) regarding postoperative GIB. The dataset was split using fivefold cross-validation into training and validation sets, in an 80/20 ratio. The performance of the models was assessed using area under the receiver operating characteristic curve (AUROC) and compared with the DeLong test. Variables with the strongest effect were identified using Shapley additive explanations (SHAP).

RESULTS

The study included 159,959 patients. Postoperative GIB was identified in 632 (0.4%) patients. The three ML methods, RF (AUROC 0.764), XGB (AUROC 0.746), and NN (AUROC 0.741) all outperformed LR (AUROC 0.709). The best ML method, RF, was able to predict postoperative GIB with a specificity and sensitivity of 70.0% and 75.4%, respectively. Using DeLong testing, the difference between RF and LR was determined to be significant with p < 0.01. Type of bariatric surgery, pre-op hematocrit, age, duration of procedure, and pre-op creatinine were the 5 most important features identified by ML retrospectively.

CONCLUSIONS

We have developed a ML model that outperformed LR in predicting postoperative GIB. Using ML models for risk prediction can be a helpful tool for both surgeons and patients undergoing bariatric procedures but more interpretable models are needed.

Preferred Feedback Styles Among Different Groups in an Academic Medical Center

INTRODUCTION

Feedback is an essential component in complex work environments. Different generations have been shown to have different sets of values, derived from societal and cultural changes. We hypothesize that generational differences may be associated with preferred feedback patterns among medical trainees and faculty in a large academic institution.

METHODS

A survey was distributed to all students, residents/fellows, and faculty at a large academic medical institution from April 2020 through June 2020. Survey questions evaluated feedback methods for six domains: preparedness, performance, attitude, technical procedures, inpatient, and outpatient care. Participants selected a preferred feedback method for each category. Patient demographics and survey responses were described using frequency statistics. We compared differences in feedback preferences based on generation and field of practice.

RESULTS

A total of 871 participants completed the survey. Preferred feedback patterns in the medical field do not seem to align with sociologic theories of generational gaps. Most participants preferred to receive direct feedback after an activity away from their team, irrespective of their age or medical specialty. Individuals preferred direct feedback during an activity in front of their team only for technical procedures. Compared to nonsurgeons, surgeons were more likely to prefer direct feedback in front of team members for preparedness, performance, and attitude.

CONCLUSIONS

Generational membership is not significantly associated with preferred feedback patterns in this complex medical academic environment. Variations in feedback preferences are associated with field of practice that may be due to specialty-specific differences in culture and personality traits present within certain medical specialties, particularly surgery.

Gastric Bypass Versus Sleeve Gastrectomy: Comparison of Patient Outcomes, Satisfaction, and Quality of Life in a Single-Center Experience

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common primary bariatric operation performed in the United States. Its relative technical ease, combined with a decreased risk for anatomic and malabsorptive complications make LSG an attractive option compared to laparoscopic gastric bypass (LGB) for many patients and surgeons. However, emerging evidence for progressive gastroesophageal reflux disease (GERD) after LSG, and the inferior weight loss in many studies, suggests that the enthusiasm for LSG requires reassessment. We hypothesized that patient satisfaction and quality of life (QoL) may be lower after LSG compared to LGB because of these differences. Methods: We distributed a survey querying weight-loss outcomes, complications, foregut symptoms, QoL, and overall satisfaction to patients who underwent bariatric operations at our institution between 2000 and 2020 and who had electronic mail contact information available. Mean follow-up was 2.75 ± 2.41 years for LGB patients and 3.37 ± 2.18 (P = .021) years for LSG patients. We compared these groups for weight-loss outcomes, changes in foregut symptoms, gastrointestinal QoL, postbariatric QoL, and overall satisfaction using appropriate statistical tests. Results: Among 323 respondents, 126 underwent LGB and 197 underwent LSG. LGB patients had larger body mass index (BMI) reduction than LSG patients (-17.16 ± 9.07 kg/m² versus -14.87 ± 7.4 kg/m², P = .023). LGB patients reported less reflux (P = .003), with decreased heartburn (P < .0001) and regurgitation (P = .0027). However, a greater proportion of LGB patients reported at least one complication (P = .025). Despite this, more LGB patients reported satisfaction (92.86%) than LSG patients (73.6%). Conclusion: LGB patients are significantly more likely to be satisfied than LSG patients. Factors contributing to the higher level of satisfaction include less GERD and better BMI decrease.

Self-compassion training to improve well-being for surgical residents

CONTEXT

Burnout remains prevalent among surgical residents. Self-compassion training may serve to improve their well-being.

OBJECTIVE

To evaluate the impact on well-being of a self-compassion program modified for surgical residents.

DESIGN

This is a 3-year, mixed-methods study using pre-post surveys and focus groups to identify areas for programmatic improvement and the subsequent impact of the modifications.

SETTING

A single academic institution.

PARTICIPANTS

Surgical residents participating in a self-compassion program.

INTERVENTIONS

A self-compassion program adapted from a larger course to fit the needs of surgical residents.

MAIN OUTCOME MEASURES

Themes relating to the program's strengths and weaknesses were identified through participant focus groups. Well-being was assessed through validated measurement tools, including The Maslach Burnout Inventory (MBI), Patient Health Questionnaire-9, Perceived Stress Scale, and Spielberger State-Trait Anxiety Inventory-6.

RESULTS

95 residents participated in the self-compassion program, of which 40 residents completed both surveys (total response rate: 42%). All participants demonstrated severe burnout pre-program, based on scores of at least one of the MBI subscales. Emotional exhaustion scores improved post-program, with larger improvements seen after program modifications (2018: 58% vs 2020: 71%). Focus group findings demonstrated that residents need a safe and distraction-free space to practice self-compassion, and program engagement improved following modifications.

Inflammation and Metabolism of Influenza-Stimulated Peripheral Blood Mononuclear Cells From Adults With Obesity Following Bariatric Surgery

BACKGROUND

Obesity dysregulates immunity to influenza infection. Therefore, there is a critical need to investigate how obesity impairs immunity and to establish therapeutic approaches that mitigate the impact of increased adiposity. One mechanism by which obesity may alter immune responses is through changes in cellular metabolism.

METHODS

We studied inflammation and cellular metabolism of peripheral blood mononuclear cells (PBMCs) isolated from individuals with obesity relative to lean controls. We also investigated if impairments to PBMC metabolism were reversible upon short-term weight loss following bariatric surgery.

RESULTS

Obesity was associated with systemic inflammation and poor inflammation resolution. Unstimulated PBMCs from participants with obesity had lower oxidative metabolism and adenosine triphosphate (ATP) production compared to PBMCs from lean controls. PBMC secretome analyses showed that ex vivo stimulation with A/Cal/7/2009 H1N1 influenza led to a notable increase in IL-6 with obesity. Short-term weight loss via bariatric surgery improved biomarkers of systemic metabolism but did not improve markers of inflammation resolution, PBMC metabolism, or the PBMC secretome.

CONCLUSIONS

These results show that obesity drives a signature of impaired PBMC metabolism, which may be due to persistent inflammation. PBMC metabolism was not reversed after short-term weight loss despite improvements in measures of systemic metabolism.

"Orphaned" Stomach-An Infrequent Complication of Gastric Bypass Revision

While generally safe, bariatric operations have a variety of possible complications. We present an uncommon complication after gastric bypass revision, namely the creation of an "orphaned" segment of remnant stomach that was left inadvertently in discontinuity, leading to recurrent intra-abdominal abscesses. Sinogram ultimately proved the diagnosis, and the issue was successfully treated using a combination of surgical and endoscopic methods to control the abscess and to allow internal drainage.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database

BACKGROUND

It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use.

METHODS

Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression.

RESULTS

A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively.

CONCLUSIONS

Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Association of Preoperative Glycosylated Hemoglobin Level with 30-Day Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of the ACS-MBSAQIP Database

PURPOSE

Elevated glycosylated hemoglobin (HbA₁c) levels have been associated with increased morbidity and mortality following several cardiac, colorectal, orthopedic, and vascular surgery operations. The purpose of this study was to determine if there is a HgA₁c cut-point that can be used in patients undergoing laparoscopic Roux-en-Y gastric bypass to decrease the risk of 30-day wound events and additional 30-day morbidity and mortality.

MATERIALS AND METHODS

All patients undergoing first-time, elective Roux-en-Y gastric bypass in 2017 and 2018 with a diagnosis of diabetes mellitus (DM) and a preoperative HbA₁c level were identified within the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative HbA₁c levels with 30-day morbidity and mortality was investigated.

RESULTS

A total of 13,806 patients met inclusion criteria. Two natural HbA₁c inflection points for composite wound events, including superficial, deep, and organ space surgical site infections (SSI) and wound dehiscence, were found. A HbA₁c level of ≤ 6.5% was associated with a decreased odds of experiencing the composite 30-day wound event outcome while a HbA₁c level of > 8.6% was associated with an increased odds of experiencing the composite 30-day wound event outcome. The differences in the incidence of the 30-day composite wound event outcomes were driven primarily by superficial and organ space SSI, including anastomotic leaks.

CONCLUSION

Patients with DM being evaluated for RYGB surgery with a HbA₁c level > 8.6% are at an increased risk for 30-day wound events, including superficial and organ space SSI.

Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See?

Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.

Autoimmune and viral risk factors are associated with achalasia: A case-control study

BACKGROUND

Achalasia is a rare esophageal motility disorder of uncertain etiology. While past studies have indicated that autoimmune conditions and viral infections may be associated with development of achalasia, these associations are yet to be examined in large, population-based studies.

METHODS

A matched case-control study was performed using administrative claim data from the IBM MarketScan Commercial Claims and Encounters Database between 2000 and 2019. A history of selected autoimmune conditions and viral infections was assessed using past medical claims. Multivariable conditional logistic regression was used to account for the matched nature of the study design and further control for confounding by demographic and clinical characteristics when reporting adjusted odds ratios (aORs).

KEY RESULTS

Among 6769 cases and 27,076 controls, presence of any of the autoimmune conditions studied was associated with increased odds of achalasia (aOR = 1.26, 95% CI: 1.11, 1.42). Scleroderma or systemic sclerosis (aOR = 8.13, 95% CI: 3.34, 19.80) and Addison's disease (aOR = 3.83, 95% CI: 1.83, 8.04) had the strongest associations with achalasia. Presence of any of the viral infections studied was also associated with an increased risk of achalasia (aOR = 1.58, 95% CI: 1.23, 2.01). Varicella zoster virus (aOR = 3.84, 95% CI: 1.94, 7.62) and human papillomavirus (aOR = 1.77, 95% CI: 1.15, 2.73) both had strong relationships with achalasia.

CONCLUSIONS AND INFERENCES

These findings suggest that achalasia may have autoimmune and viral components contributing to its etiology. Future mechanistic studies could target specific diseases and agents highlighted by this research.

Roux-en-Y Gastric Bypass Is Associated With Increased Hazard for De Novo Alcohol-related Complications and Liver Disease

GOAL

The goal of this study was to determine if bariatric surgeries are associated with de novo alcohol-related complications.

BACKGROUND

Bariatric surgery is associated with an increased risk of alcohol use disorders. The effect of bariatric surgeries on other alcohol-related outcomes, including liver disease, is understudied.

MATERIALS AND METHODS

Using the IMS PharMetrics database, we performed a cohort study of adults undergoing bariatric surgery or cholecystectomy, excluding patients with an alcohol-related diagnosis within 1 year before surgery. The primary outcome was any alcohol-related diagnosis after surgery. We fit a multivariable Cox proportional hazards model to determine independent associations between bariatric surgeries [Roux-en-Y gastric bypass (RYGB); adjustable gastric band; sleeve gastrectomy] versus cholecystectomy and the development of de novo alcohol-related outcomes. We further fit complication-specific models for each alcohol-related diagnosis.

RESULTS

RYGB was significantly associated with an increased hazard of any de novo alcohol-related diagnosis [adjusted hazard ratio (AHR)=1.51, 95% confidence interval (CI): 1.40-1.62], while adjustable gastric band (AHR=0.55, 95% CI: 0.48-0.63) and sleeve gastrectomy (AHR=0.77, 95% CI: 0.64-0.91) had decreased hazards. RYGB was associated with a 2- to 3-fold higher hazard for alcoholic hepatitis (AHR=1.98, 95% CI: 1.17-3.33), abuse (AHR=2.05, 95% CI: 1.88-2.24), and poisoning (3.14, 95% CI: 1.80-5.49).

CONCLUSIONS

RYGB was associated with higher hazards of developing de novo alcohol-related hepatitis, abuse, and poisoning compared with a control group. Patients without a history of alcohol use disorder should still be counseled on the increased risk of alcohol use and alcohol-related complications, including alcohol-related liver disease, following RYGB, and should be monitored long term for the development of alcohol-related complications.

Evaluating the Ergonomics of Surgical Residents During Laparoscopic Simulation: A Novel Computerized Approach

BACKGROUND

Assessment of residents' body positioning during laparoscopy has not been adequately investigated. This study presents a novel computer vision technique to automate ergonomic evaluation and demonstrates this approach through simulated laparoscopy.

METHODS

Surgical residents at a single academic institution were video recorded performing tasks from the Fundamentals of Laparoscopic Surgery (FLS). Ergonomics were assessed by 2 raters using the Rapid Upper Limb Assessment (RULA) tool. Additionally, a novel computer software program was used to measure ergonomics from the video recordings. All participants completed a survey on musculoskeletal complaints, which was graded by severity.

RESULTS

Ten residents participated; all performed FLS in postures that exceeded acceptable ergonomic risks as determined by both the human and computerized RULA scores (P < .001). Lower-level residents scored worse than upper-level residents on the human-graded RULA assessment (P = .04). There was no difference in computer-graded RULA scores by resident level (P = .39) and computer-graded scores did not correlate with human scores (P = .75). Shoulder and wrist position were the greatest contributors to higher computer-graded scores (P < .001). Self-reported musculoskeletal complaints did not differ at resident level (P = .74); however, all residents reported having at least 1 form of musculoskeletal complaint occurring "often."

CONCLUSIONS

Surgery residents demonstrated suboptimal ergonomics while performing simulated laparoscopic tasks. A novel computer program to measure ergonomics did not agree with the scores generated by the human raters, although it concluded that resident ergonomics remain a concern, especially regarding shoulder and wrist positioning.

Minimally invasive Heller myotomy with partial posterior fundoplication for the treatment of achalasia: long-term results from a tertiary referral center

INTRODUCTION

Few studies have reported the long-term results of minimally invasive Heller myotomy (HM) for the treatment of achalasia. Herein, we detail our 17-year experience with HM for the treatment of achalasia from a tertiary referral center.

METHODS

All patients undergoing elective HM at our institution from 2000 to 2017 were identified within a prospective institutional database. These patients were sent mail and electronic surveys to capture their symptoms of dysphagia, chest pain, and regurgitation pre- and postoperatively and were asked to evaluate their postoperative gastrointestinal quality of life. Responses from adult patients who underwent minimally invasive Heller myotomy with partial posterior (i.e., Toupet) fundoplication (HM-TF) were analyzed.

RESULTS

294 patients were eligible for study inclusion; 139 (47%) completed our survey. Median time from HM-TF to survey response was 5.6 years. A majority of patients reported improvement in their dysphagia (91%), chest pain (70%), and regurgitation (87%) symptoms. Patients who underwent HM-TF more than 5 years ago were most likely to report heartburn symptoms. One (1%) patient went on to require esophagectomy for ongoing dysphagia and one (1%) patient required revisional fundoplication for their heartburn symptoms.

CONCLUSIONS

Minimally invasive Heller myotomy and posterior partial fundoplication is a durable treatment for achalasia over the long term. Additional prospective and multi-institutional studies are needed to validate our results.

Preparation for Challenging Cases: What Differentiates Expert From Novice Surgeons?

OBJECTIVE

The study of expert performance provides a rich field for exploration in the surgical literature. This study aimed to examine the difference between expert and novice surgeons in their preparation for challenging cases.

DESIGN

Expert (attending) and novice (postgraduate-year 2) surgeons were presented two cases of complicated cholecystitis and were asked how they would prepare, what they would expect to encounter intraoperatively, and how they would deal with these challenges. Their responses were recorded, transcribed verbatim and analyzed using thematic analysis.

SETTING

Academic teaching hospitals.

PARTICIPANTS

Two group of expert and novice surgeons.

RESULTS

Nine experts and eleven novices from two academic centers participated. The majority of novices focused on patient history, work-up, preoperative optimization, anatomy, and anticipation of intraoperative challenges. In addition to the patient's presentation and preoperative optimization, most experts' thoughts were directed toward preparation for surgery (level of urgency, required skills in surgical team, case difficulty, and risk of conversion to open). Experts would involve the patient in the decision-making and were more likely to communicate with the operating room team. While novices attempted to predict challenges depending on gallbladder condition and intra-abdominal adhesions, the experts highlighted the importance of various elements of the operative field, the detail of the technique and possible challenges, and their troubleshooting plans. Regarding operative planning to address anticipated challenges, novices would tailor their plan to patient characteristics and verbalized an analytical "if-then" approach for all possibilities they might encounter. Experts would start with their standard technique regardless of case complexity and would deal with contingencies as they arise. Safety was a critical part of expert surgeons' plans.

CONCLUSIONS

Novices mostly conveyed descriptive knowledge based on presented facts while experts demonstrated an ability to paint a richer mental image of possible future events by creating comprehensive anticipation of the operative field. Further studies are needed to validate the results of this study.

The Endoscopic Management of Achalasia: Less May Lead to More

Achalasia is a rare motor disorder of the lower esophageal sphincter. Currently, both endoscopic and surgical techniques are used to treat achalasia. Herein, we detail our institutional experience of surgical re-intervention following the endoscopic management of achalasia.

Refractory Hypocalcemia Following Stomach Intestinal Pylorus-Sparing Bariatric Surgery and Thyroidectomy: Successful Management With Creation of a Proximal Roux-en-Y Gastric Bypass

Some forms of bariatric surgery make patients susceptible to calcium malabsorption, and the parathyroid hormone (PTH) axis is important for maintaining normocalcemia in these patients. Injury to the parathyroid glands due to anterior neck surgery commonly causes PTH axis disruption and can result in severe hypocalcemia in bariatric surgery patients. Herein, we present a case of a patient with a history of stomach intestinal pylorus-sparing bariatric surgery who developed refractory hypocalcemia requiring daily intravenous (IV) calcium 2 years after thyroidectomy. PTH levels were inappropriately normal during episodes of hypocalcemia, and urinary calcium level was <3.0 mg/dL following large oral doses of calcium, suggesting that both inadequate PTH response and malabsorption contributed to her severe hypocalcemia. In order to enhance calcium absorptive capacity while minimizing the risk of weight regain, she was surgically treated with a Roux-en-Y gastric bypass proximal to the prior operation. The surgery successfully improved blood calcium levels; the patient was successfully weaned from IV calcium and was able to maintain normocalcemia with oral supplements. We discuss the case in the context of available literature and provide our recommendations.

Pilot Study Using Neurofeedback as a Tool to Reduce Surgical Resident Burnout

BACKGROUND

Burnout is prevalent among surgical residents. Neurofeedback is a technique to train the brain in self-regulation skills. We aimed to assess the impact of neurofeedback on the cognitive workload and personal growth areas of surgery residents with burnout and depression.

STUDY DESIGN

Fifteen surgical residents with burnout (Maslach Burnout Inventory [MBI] score > 27) and depression (Patient Health Questionnaire-9 Depression Screen [PHQ-9] score >10), from 1 academic institution, were enrolled and participated in this institutional review board-approved prospective study. Ten residents with more severe burnout and depression scores were assigned to receive 8 weeks of neurofeedback treatments, and 5 others with less severe symptoms were treated as controls. Each participant's cognitive workload (or mental effort) was assessed initially, and again after treatment via electroencephalogram (EEG) while the subjects performed n-back working memory tasks. Analysis of variance (ANOVA) tested for significance between the degree of change in the treatment and control groups. Each subject was also asked to rate changes in growth areas, such as sleep and stress.

RESULTS

Both groups showed high cognitive workload in the pre-assessment. After the neurofeedback intervention, the treatment group showed a significant (p < 0.01) improvement in cognitive workload via EEG during the working memory task. These differences were not noted in the control group. There was significant correlation between time (NFB sessions) and average improvement in all growth areas (r = 0.98) CONCLUSIONS: Residents demonstrated high levels of burnout, correlating with EEG patterns indicative of post-traumatic stress disorder. There was a notable change in cognitive workload after the neurofeedback treatment, suggesting a return to a more efficient neural network.

The Impact of the COVID-19 Pandemic on Surgical Practice in the Southeastern United States: Results of a Survey of the Membership of the Southeastern Surgical Congress

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic dramatically altered the delivery of surgical care.

METHODS

Members of the Southeastern Surgical Congress were surveyed regarding system adjustments, personal impact, and productivity losses. Subgroups were analyzed for disproportionate impact across practice models (academic/employed/private), practice communities (urban, suburban, rural), and practice case-mix categories (broad general surgery, narrow general surgery, specialty practice, hospital-based practice).

RESULTS

135 respondents reported that 98.5% of surgeons and 97% of hospitals canceled elective cases. Practices and hospitals reduced staffing dramatically. Telemedicine was utilized by most respondents. Hospitals variably implemented system changes, developed tests, and set up diagnostic centers. Most surgeons anticipated resumption of practice and hospital activity by July 1, 2020. More than one-quarter reported worsened financial status and personal well-being. Interestingly, family/personal relationships were improved in more than one-third. Most surgeons anticipate reduced year-end case volumes, clinical productivity, and salary. In subgroup analyses, academic surgeons were more likely than employed and private-practice surgeons to use telemedicine and to work in hospitals with in-house COVID-19 testing. Private-practice surgeons expected decreased financial status, case volumes, relative value units (RVUs), and salary. More rural surgeons anticipate reduced salary than urban and suburban surgeons. Surgeons in narrow general surgery practice reported more furlough of employees than specialty surgeons, hospital-based surgeons, and broad-based general surgeons. Narrow-practice surgeons and specialists were more likely to report RVU reductions and improved family/personal relationships.

DISCUSSION

The COVID-19 slowdown affected surgeons throughout the southeastern United States. Variations between different practice models, communities, and case-mix categories may help inform surgeons in the future.

Laparoscopic Posterior Partial Fundoplication for Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common condition that greatly impacts quality of life. Management options include medical and surgical therapies. Nonoperative management typically relies on longitudinal use of acid-suppressive medications such as proton pump inhibitors, which is associated with a significant financial burden and an increasing number of recognized side effects. The surgical management of GERD is focused on correction of the lower esophageal sphincter dysfunction by means of a fundoplication, thus limiting acid and nonacid gastroesophageal reflux. Multiple techniques have been described, including use of complete (360°) fundoplication or partial fundoplication in either an anterior (180°) or posterior (220-270°) position. Recent studies have shown that the total and the partial fundoplications are similarly effective in controlling GERD. A partial fundoplication may also be advantageous when treating patients with GERD and poor esophageal motility. This article focuses on the posterior partial (modified Toupet) fundoplication, with attention to the key elements of the preoperative workup, appropriate patient selection, and important technical steps that are associated with the best outcomes.

Antireflux Surgery for Gastroesophageal Reflux Refractory to Medical Treatment After Peroral Endoscopic Myotomy

Background: Between 1995 and 2010, the laparoscopic Heller myotomy (LHM) was considered in most centers the treatment of choice for esophageal achalasia. The technique evolved over time, and the initial thoracoscopic approach was abandoned in favor of LHM with the addition of a fundoplication, due to the high incidence of postoperative reflux. Recently, a new endoscopic technique has been adopted in the treatment of achalasia-peroral endoscopic myotomy (POEM), which has slowly become the preferred treatment modality in many centers. While POEM is as effective as LHM in relieving symptoms, it has been associated with a very high rate of pathological reflux, development of strictures, Barrett's esophagus, and adenocarcinoma. In addition, many patients still complain of heartburn and regurgitation even when treated with high doses of proton pump inhibitors. Methods: We described 3 cases of achalasia patients with reflux symptoms refractory to medical treatment after POEM who underwent laparoscopic antireflux surgery. Results: The operations were completed laparoscopically despite presence of mediastinal adhesions, probably secondary to micro-leaks during POEM. All patients had resolution of their symptoms. Conclusions: This is the first report that describes patients who developed severe heartburn and regurgitation refractory to medical treatment following POEM, who eventually underwent a laparoscopic partial fundoplication with resolution of their symptoms. Our experience shows that post-POEM reflux is a serious concern, especially when refractory to medical treatment. We feel that this is a worrisome problem that will require frequent surgical interventions in the future.

Multiple-Institution Comparison of Resident and Faculty Perceptions of Burnout and Depression During Surgical Training

Importance

Prior studies demonstrate a high prevalence of burnout and depression among surgeons. Limited data exist regarding how these conditions are perceived by the surgical community.

Objectives

To measure prevalence of burnout and depression among general surgery trainees and to characterize how residents and attendings perceive these conditions.

Design, Setting, and Participants

This cross-sectional study used unique, anonymous surveys for residents and attendings that were administered via a web-based platform from November 1, 2016, through March 31, 2017. All residents and attendings in the 6 general surgery training programs in North Carolina were invited to participate.

Main Outcomes and Measures

The prevalence of burnout and depression among residents was assessed using validated tools. Burnout was defined by high emotional exhaustion or depersonalization on the Maslach Burnout Inventory. Depression was defined by a score of 10 or greater on the Patient Health Questionnaire-9. Linear and logistic regression models were used to assess predictive factors for burnout and depression. Residents' and attendings' perceptions of these conditions were analyzed for significant similarities and differences.

Results

In this study, a total of 92 residents and 55 attendings responded. Fifty-eight of 77 residents with complete responses (75%) met criteria for burnout, and 30 of 76 (39%) met criteria for depression. Of those with burnout, 28 of 58 (48%) were at elevated risk of depression (P = .03). Nine of 77 residents (12%) had suicidal ideation in the past 2 weeks. Most residents (40 of 76 [53%]) correctly estimated that more than 50% of residents had burnout, whereas only 13 of 56 attendings (23%) correctly estimated this prevalence (P < .001). Forty-two of 83 residents (51%) and 42 of 56 attendings (75%) underestimated the true prevalence of depression (P = .002). Sixty-six of 73 residents (90%) and 40 of 51 attendings (78%) identified the same top 3 barriers to seeking care for burnout: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care.

Conclusions and Relevance

The prevalence of burnout and depression was high among general surgery residents in this study. Attendings and residents underestimated the prevalence of these conditions but acknowledged common barriers to seeking care. Discrepancies in actual and perceived levels of burnout and depression may hinder wellness interventions. Increasing understanding of these perceptions offers an opportunity to develop practical solutions.

Toward effective feedback: From concept to practice

Feedback is the building block of assessment and an essential component of effective teaching. In this article, we will provide a comprehensive definition of feedback and a relevant conceptual framework for learning to explain how feedback can be used to improve performance. We will discuss the process of providing feedback, and the role teacher and learner can play to make it more effective. We will also examine the misunderstandings and pitfalls around feedback, as well as generational differences that may influence its impact.

Trends in Utilization and Relative Complication Rates of Bariatric Procedures

BACKGROUND

Laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding have been popular alternatives to laparoscopic Roux-en-Y gastric bypass due to their technical ease and lower complication rates. Comprehensive longitudinal data are necessary to guide selection of the appropriate bariatric procedures for individual patients.

METHODS

We used the Truven Heath Analytics MarketScan® database between 2000 and 2015 to identify patients undergoing bariatric surgery. Kaplan-Meier and Cox proportional hazard regression analyses were performed to compare complication rates between laparoscopic gastric bypass and laparoscopic sleeve gastrectomy, as well as between laparoscopic gastric bypass and laparoscopic adjustable gastric banding.

RESULTS

256,830 individuals met search criteria. By 2015, laparoscopic sleeve gastrectomy was the most commonly performed bariatric procedure followed by laparoscopic gastric bypass and then laparoscopic adjustable gastric banding. Overall, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding had fewer complications relative to laparoscopic gastric bypass with the exceptions of heartburn, gastritis, and portal vein thrombosis following sleeve gastrectomy and heartburn and dysphagia following adjustable gastric banding.

CONCLUSION

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric procedure in the USA. It is reassuring that its overall postoperative complication rates are lower relative to laparoscopic gastric bypass.

Detection of low-density Plasmodium falciparum infections using amplicon deep sequencing

BACKGROUND

Deep sequencing of targeted genomic regions is becoming a common tool for understanding the dynamics and complexity of Plasmodium infections, but its lower limit of detection is currently unknown. Here, a new amplicon analysis tool, the Parallel Amplicon Sequencing Error Correction (PASEC) pipeline, is used to evaluate the performance of amplicon sequencing on low-density Plasmodium DNA samples. Illumina-based sequencing of two Plasmodium falciparum genomic regions (CSP and SERA2) was performed on two types of samples: in vitro DNA mixtures mimicking low-density infections (1-200 genomes/μl) and extracted blood spots from a combination of symptomatic and asymptomatic individuals (44-653,080 parasites/μl). Three additional analysis tools-DADA2, HaplotypR, and SeekDeep-were applied to both datasets and the precision and sensitivity of each tool were evaluated.

RESULTS

Amplicon sequencing can contend with low-density samples, showing reasonable detection accuracy down to a concentration of 5 Plasmodium genomes/μl. Due to increased stochasticity and background noise, however, all four tools showed reduced sensitivity and precision on samples with very low parasitaemia (< 5 copies/μl) or low read count (< 100 reads per amplicon). PASEC could distinguish major from minor haplotypes with an accuracy of 90% in samples with at least 30 Plasmodium genomes/μl, but only 61% at low Plasmodium concentrations (< 5 genomes/μl) and 46% at very low read counts (< 25 reads per amplicon). The four tools were additionally used on a panel of extracted parasite-positive blood spots from natural malaria infections. While all four identified concordant patterns of complexity of infection (COI) across four sub-Saharan African countries, COI values obtained for individual samples differed in some cases.

CONCLUSIONS

Amplicon deep sequencing can be used to determine the complexity and diversity of low-density Plasmodium infections. Despite differences in their approach, four state-of-the-art tools resolved known haplotype mixtures with similar sensitivity and precision. Researchers can therefore choose from multiple robust approaches for analysing amplicon data, however, error filtration approaches should not be uniformly applied across samples of varying parasitaemia. Samples with very low parasitaemia and very low read count have higher false positive rates and call for read count thresholds that are higher than current default recommendations.

Myotomy-First Approach to Epiphrenic Esophageal Diverticula

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux

Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.

Surgeons' expertise during critical event in laparoscopic cholecystectomy: An expert-novice comparison using protocol analysis

BACKGROUND

The purpose of this study was to examine differences in thought processes between novice and experienced surgeons when they were presented with a critical situation during laparoscopic cholecystectomy.

METHODS

A group of experienced and novice surgeons were shown a recording of a laparoscopic cholecystectomy with an intraoperative bleeding event. The think-aloud method was used to capture surgeons' thought processes. Verbal reports were recorded, transcribed and analyzed using the protocol analysis method.

RESULTS

Sixteen subjects (8 in each group) participated at two centers. Experienced surgeons demonstrated deeper comprehension of the operative field, richer mental image of future events and superior awareness of potentially dangerous situations. They also spent more time engaged in metacognitive activity.

CONCLUSIONS

This study highlights the differences and similarities between surgeons with different levels of experience during a challenging intraoperative encounter. The domains of cognition and mental image as well as metacognition appear to be key elements of surgical expertise.

Sleeve Gastrectomy: Surgical Tips

The vertical sleeve gastrectomy is a bariatric procedure that was originally described as the initial step in the biliopancreatic diversion. It demonstrated effectiveness in weight loss as a single procedure, and the laparoscopic vertical sleeve gastrectomy, as a stand-alone procedure, is now the most commonly performed bariatric surgery worldwide. Due to its relative technical ease and long-term data that have established its durability in treating obesity and its related comorbid conditions, the sleeve gastrectomy has grown in popularity among patients and surgeons. While there are variations in the technical aspects of performing a laparoscopic sleeve gastrectomy, key steps must be undertaken to produce safe and effective outcomes. This article reviews the indications for bariatric surgery, patient selection, surgical technique and tips, perioperative care and complications after sleeve gastrectomy.

The Treatment of Achalasia in Obese Patients

Epidemiological studies have demonstrated that obesity is frequently associated with esophageal motility disorders. Morbid obesity and achalasia may coexist in the same patient. The management of the morbidly obese patient with achalasia is complex and the most effective treatment remains controversial. The aim of this study is to review the pathophysiology, clinical presentation, diagnostic evaluation, and treatment of achalasia in morbidly obese patients.

EVIDENCE REVIEW

PubMed search from January 1990 to July 2017, including the following terms: achalasia, morbid obesity, bariatric, and treatment. Achalasia in the setting of morbid obesity may be successfully treated by endoscopic or surgical methods. Surgeons may choose to add a bariatric procedure, with various strategies present in the literature. A review of the present literature suggests that the preferred approach to achalasia in the morbidly obese patient is to address both disease processes simultaneously with a laparoscopic Heller myotomy and a Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is cited by most experts as the bariatric procedure of choice, given its antireflux benefits. A well-powered study, comparing the various approaches to the treatment of achalasia in the setting of morbid obesity, is required to establish a consensus.

The Treatment of Achalasia in Obese Patients

Epidemiological studies have demonstrated that obesity is frequently associated with esophageal motility disorders. Morbid obesity and achalasia may coexist in the same patient. The management of the morbidly obese patient with achalasia is complex and the most effective treatment remains controversial. The aim of this study is to review the pathophysiology, clinical presentation, diagnostic evaluation, and treatment of achalasia in morbidly obese patients. Evidence Review: PubMed search from January 1990 to July 2017, including the following terms: achalasia, morbid obesity, bariatric, and treatment. Achalasia in the setting of morbid obesity may be successfully treated by endoscopic or surgical methods. Surgeons may choose to add a bariatric procedure, with various strategies present in the literature. A review of the present literature suggests that the preferred approach to achalasia in the morbidly obese patient is to address both disease processes simultaneously with a laparoscopic Heller myotomy and a Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is cited by most experts as the bariatric procedure of choice, given its antireflux benefits. A well-powered study, comparing the various approaches to the treatment of achalasia in the setting of morbid obesity, is required to establish a consensus.

Oral Anticoagulant Use After Bariatric Surgery: A Literature Review and Clinical Guidance

Bariatric surgery may alter the absorption, distribution, metabolism, or elimination (disposition) of orally administered drugs via changes to the gastrointestinal tract anatomy, body weight, and adipose tissue composition. As some patients who have undergone bariatric surgery will need therapeutic anticoagulation for various indications, appropriate knowledge is needed regarding anticoagulant drug disposition and resulting efficacy and safety in this population. We review general considerations about oral drug disposition in patients after bariatric surgery, as well as existing literature on oral anticoagulation after bariatric surgery. Overall, available evidence on therapeutic anticoagulation is very limited, and individual drug studies are necessary to learn how to safely and effectively use the direct oral anticoagulants. Given the sparsity of currently available data, it appears most prudent to use warfarin with international normalized ratio monitoring, and not direct oral anticoagulants, when full-dose anticoagulation is needed after bariatric surgery.

Minimally Invasive Surgery Should Be the Standard of Care for Paraesophageal Hernia Repair

BACKGROUND

It is unclear if minimally invasive surgery (MIS) has been universally embraced for paraesophageal hernia (PEH) repair. The aims of this study were: (a) to assess the national utilization of MIS for PEH repair and (b) to compare the perioperative outcomes between MIS and open procedures METHODS: A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2013. Adult patients (≥18 years old) who underwent PEH repair were included. Linear and logistic regression, adjusted for patient and hospital characteristics, were used to assess the effect of minimally invasive surgery on patient outcomes RESULTS: A total of 63,812 patients were included. An abdominal approach was used in 60,087 (94.2%) patients and a thoracic approach in 3725 (5.8%) cases. Between 2000 and 2013, the rate of MIS significantly increased in abdominal and thoracic procedures. Patients undergoing MIS were less likely to experience postoperative infection, bleeding, cardiac failure, renal failure, respiratory failure, shock, and had a lower inpatient mortality. In addition, MIS significantly reduced the length of hospital stay and the overall cost.

CONCLUSIONS

MIS is associated with significantly better perioperative outcomes and lower costs. These data strongly support the MIS approach as standard of care for PEH repair.

Surgery for Gastroesophageal Reflux Disease in the Morbidly Obese Patient

The prevalence of gastroesophageal reflux disease (GERD) has mirrored the increase in obesity, and GERD is now recognized as an obesity-related comorbidity. There is growing evidence that obesity, specifically central obesity, is associated with the complications of chronic reflux, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. While fundoplication is effective in creating a competent gastroesophageal junction and controlling reflux in most patients, it is less effective in morbidly obese patients. In these patients a bariatric operation has the ability to correct both the obesity and the abnormal reflux. The Roux-en-Y gastric bypass is the preferred procedure.

Fundoplication for Gastroesophageal Reflux Disease: Tips for Success

Gastroesophageal reflux disease affects almost 20% of the population in the United States. Today, proton pump inhibitors are the most frequently prescribed drugs, with an estimated cost of 10 billion dollars per year. Although these medications control heartburn in the majority of patients, other symptoms such as regurgitation and respiratory symptoms often are not controlled, particularly in patients with large hiatal hernias. In these patients a properly performed laparoscopic fundoplication controls esophageal and extraesophageal symptoms and avoids life-long medical therapy. Key elements for the success of a fundoplication are careful patient selection, a complete preoperative evaluation, and a properly executed operation.

Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval

Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan–Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m2) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial ( P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.

Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval

Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan-Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m(2)) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial (P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.