The mini-fellowship concept: a six-week focused training program for minimally invasive bariatric surgery

The Impact of Metabolic and Bariatric Surgeon Status on Outcomes After Bariatric Surgery: a Retrospective Cohort Study Using the MBSAQIP Database

PURPOSE

Differences between complication rates of bariatric surgeries performed by general surgeons (GS) versus those performed by metabolic and bariatric surgeons (MBS) are poorly understood.

METHODS

We analyzed the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database focusing on RYGB and SG procedures between 2016 and 2019. Our primary objective was to evaluate trends in the number of bariatric procedures performed by GS and MBS. Secondary objectives were assessing for differences in 30-day mortality and the incidence of serious complications. Differences between groups were evaluated by chi-squared analysis for categorical data and ANOVA tests for continuous data. A multivariable logistic regression was performed to determine the influence of subspecialized training on the incidence of serious complications and 30 day mortality.

RESULTS

A total of 622,079 patients were analyzed, 15,485 were operated on by GS (2.5%, mean age 44.7 years, mean BMI 45.2 kg/m²), while 606,594 procedures were performed by MBS (97.5%, mean age 44.4 years, mean BMI 45.2 kg/m²). The proportion of procedures being completed by the GS group decreased from n=4662, 3.2% in 2016, to n=3414, 2.1% in 2019. After adjusting for comorbidities, MBS patients did not have differences in death at 30 days (OR 1.26 [0.67-2.38], p=0.467) or serious complications (OR 0.97 [0.89-1.06], p=0.554).

CONCLUSION

The majority of bariatric procedures are being completed by MBS with the proportion completed by GS decreasing. We found no difference in the number of serious complications and 30-day mortality rates across the MBS and GS groups. Graphical abstract.

Transversus abdominis release (TAR): what are the real indications and where is the limit?

PURPOSE

To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure.

METHODS

Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center.

RESULTS

Recommendations regarding patient selection, optimization and technique for TAR are presented.

CONCLUSIONS

While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.

Training in Bariatric Surgery: a National Survey of German Bariatric Surgeons

INTRODUCTION

Skill in bariatric surgery has been associated with postoperative outcome. Appropriate surgical training is of paramount importance. In order to continuously improve training strategies, it is necessary to assess current practices.

AIM

To determine how German bariatric surgeons have been trained and to assess current training strategies.

METHODS

Between February 2017 and March 2017, an online census of surgeons registered as members of the German Society for Bariatric and Metabolic Surgery was conducted. A total of three reminders were sent out. Data were analyzed using descriptive statistics. Data was reported as median (interquartile range); percentages were adjusted for completed answers only.

RESULTS

A response rate of 51% (n = 214) was achieved. Surgeons reported a median of 14.5 (8-20) years of surgical experience after initial training, with a specific bariatric experience of 7 (4-13) years. The total cumulative bariatric case volume was 240 (80-500) cases, with an annual case volume of 50 (25-80). The most commonly applied approaches to bariatric skills acquisition were "learning by doing" (71%), "course participation" (70%) and "observerships" (70%). Fellowships and the use of operating videos were less frequently applied strategies (19%/ 47%). Interestingly, observerships (94%) and course participation (89%) were rated as very important/important, whereas "learning by doing" (62%), watching operation videos (59%), and fellowships (48%) were less frequently perceived as important/very important training strategies.

CONCLUSIONS

The majority of surgeons performing bariatric cases were senior surgeons with more than 10 years of post-training experience; nevertheless, the survey revealed a lack of structured approaches to bariatric specialization training.

Strategies for New Skill Acquisition by Practicing Surgeons

OBJECTIVE

To understand how practicing surgeons utilize available training methods, which methods are perceived as effective, and important barriers to using more effective methods.

DESIGN

Online survey designed to characterize surgeon utilization and perception of available training methods.

SETTING

Two large Midwestern academic health centers.

PARTICIPANTS

150 faculty surgeons.

METHODS

Nominal values were compared using a McNemar's Test and Likert-like values were compared using a paired t-test (IBM SPSS Statistics v. 21.0; New York, NY).

RESULTS

Survey response rate was 81% (122/150). 98% of surgeons reported learning a new procedure or technology after formal training. Many surgeons reported scrubbing in expert cases (78%) and self-directed study (66%), while few surgeons (6%) completed a mini-fellowship. The modalities used most commonly were scrubbing in expert cases (34%) and self-directed study (27%). Few surgeons (7%) believed self-directed study would be most effective, whereas 31% and 16% believed operating under supervision and mini-fellowships would be most effective, respectively. Surgeons believed more effective methods "would require too much time" or they had "confidence in their ability to implement safely."

CONCLUSIONS

Practicing surgeons use a variety of training methods when learning new procedures and technologies, and there is disconnect between commonly used training methods and those deemed most effective. Confidence in surgeon's ability was cited as a reason for this discrepancy; and surgeons found time associated with more effective methods to be prohibitive.

Safety considerations in learning new procedures: a survey of surgeons

BACKGROUND

There exists a tension between surgical innovation and safety. The learning curve associated with the introduction of new procedures/technologies has been associated with preventable patient harm. Surgeon's perceptions regarding the safety of methods for learning new procedures/technologies are largely uncharacterized.

MATERIALS AND METHODS

A survey was designed to evaluate surgeons' perceptions related to learning new procedures/technologies. This included clinical vignettes across two domains: (1) experience with an operation (e.g., colectomy) and (2) experience with a technology (e.g., laparoscopy). This study also focuses on a surgeon's perceptions of existing credentialing/privileging requirements. Participants were faculty surgeons (n = 150) at two large Midwestern academic health centers.

RESULTS

Survey response rate was 77% (116/150). 69% of respondents believed the processes of credentialing/privileging is "far too relaxed" or "too relaxed" for ensuring patient safety. Surgeons most commonly indicated a mini-fellowship is required to learn a new laparoscopic procedure. However, that requirement differed based on a surgeon's prior experience with laparoscopy. For example, to learn laparoscopic colectomy, 35% of respondents felt a surgeon with limited laparoscopic experience should complete a mini-fellowship, whereas 3% felt this was necessary if the surgeon had extensive laparoscopic experience. In the latter scenario, most respondents felt a surgeon should scrub in cases performed by an expert (38%) or perform cases under a proctor's supervision (33%) when learning laparoscopic colectomy.

CONCLUSIONS

Many surgeons believe existing hospital credentialing/privileging practices may be too relaxed. Moreover, surgeons believe the "one-size-fits-all" approach for training practicing surgeons may not protect patients from unsafe introduction of new procedures/technologies.

The cutting-edge training modalities and educational platforms for accredited surgical training: A systematic review

Background:

Historically, operating room (OR) has always been considered as a stand-alone trusted platform for surgical education and training. However, concerns about financial constraints, quality control, and patient safety have urged the surgical educators to develop more cost-effective, surgical educational platforms that can be employed outside the OR. Furthermore, trained surgeons need to regularly update their surgical skills to keep abreast with the emerging surgical technologies. This research aimed to explore the value of currently available modern surgical tools that can be used outside the OR and also elaborates the existing laparoscopic surgical training programs in world-class centers across the globe with a view to formulate a blended and unified structured surgical training program.

Materials and Methods:

Several data sources were searched using MeSH terms “Laparoscopic surgery” and “Surgical training” and “Surgical curriculum” and “fundamentals of endoscopic surgery” and “fundamentals of laparoscopic surgery” and “Telementoring” and “Box trainer.” The eligibility criteria used in data extraction searched for original and review articles and by excluding the editorial articles, short communications, conference proceedings, personal view, and commentaries. Data synthesis and data analysis were done by reviewing the initially retrieved 211 articles. Irrelevant and duplicate and redundant articles were excluded from the study.

Results:

Finally, 12 articles were selected for this systematic review. Data results showed that a myriad of cutting-edge technical innovations have provided modern surgical training tools such as the simulation-based mechanical and virtual reality simulators, animal and cadaveric labs, telementoring, telerobotic-assisted surgery, and video games. Surgical simulators allow the trainees to acquire surgical skills in a tension-free environment without supervision or time constraints.

Conclusion:

The existing world-renowned surgical training centers employ various clusters of training tools that essentially endeavor to embed the acquisition of knowledge and technical skills. However, a unified training curriculum that may be accepted worldwide is currently not available.

Impact of continuous training through distributed practice for acquisition of minimally invasive surgical skills

BACKGROUND

Minimally invasive surgery (MIS) requires the mastery of manual skills and a specific training is required. Apart from residencies and fellowships in MIS, other learning opportunities utilize massive training, mainly with use of simulators in short courses. A long-term postgraduate course represents an opportunity to learn through training using distributed practice.

OBJECTIVE

The objective of this study is to assess the use of distributed practice for acquisition of basic minimally invasive skills in surgeons who participated in a long-term MIS postgraduate course.

METHODS

A prospective, longitudinal and quantitative study was conducted among surgeons who attended a 1-year postgraduate course of MIS in Brazil, from 2012 to 2014. They were tested through five different exercises in box trainers (peg-transfer, passing, cutting, intracorporeal knot, and suture) in the first (t0), fourth (t1) and last, eighth, (t2) meetings of this course. The time and penalties of each exercise were collected for each participant. Participant skills were assessed based on time and accuracy on a previously tested score.

RESULTS

Fifty-seven surgeons (participants) from three consecutive groups participated in this study. There was a significant improvement in scores in all exercises. The average increase in scores between t0 and t2 was 88% for peg-transfer, 174% for passing, 149% for cutting, 130% for intracorporeal knot, and 120% for suture (p < 0.001 for all exercises).

CONCLUSION

Learning through distributed practice is effective and should be integrated into a MIS postgraduate course curriculum for acquisition of core skills.

Simulation-based training and learning curves in laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Ex vivo simulation-based technical skills training has been shown to improve operating room performance and shorten learning curves for basic laparoscopic procedures. The application of such training for laparoscopic Roux-en-Y gastric bypass (LRYGBP) has not been reviewed.

METHODS

Relevant studies were identified by one author from a search of MEDLINE and Embase databases from 1 January 1994 to 30 November 2010. Studies examining the learning curves and ex vivo training methods for LRYGBP were included; all other types of bariatric operations were excluded. A manual search of the references was also performed to identify additional potentially relevant papers.

RESULTS

Twelve studies (5 prospective and 7 retrospective case series) were selected for review. The learning curve for LRYGBP was reported to be 50-100 procedures. Bench-top laparoscopic jejunojejunostomy, anaesthetized animals and Thiel human cadavers made up the bulk of the reported models for ex vivo training. Most studies were of relatively poor quality. An evidence-based ex vivo training curriculum for LRYGBP is currently lacking.

CONCLUSION

Better quality studies are needed to define the learning curve for LRYGBP. Future studies should focus on the design and validation of training models, and a comprehensive curriculum for training and assessment of cognitive, technical and non-technical components of competency for laparoscopic bariatric surgery.

Surgical resident participation in laparoscopic Roux-en-Y bypass: Is it safe?

BACKGROUND

The majority of bariatric surgeons use dedicated surgical assistants when performing laparoscopic Roux-en-Y gastric bypass (LGBP) because of the technical difficulty and steep learning curve involved in the operation. At our institution, either a senior surgical resident (SSR) or a physician assistant (PA) participates in LGBP cases. The PA's role is confined to assisting, whereas the SSR progressively acts as the operating surgeon. We were interested in evaluating patient outcomes to determine whether any differences existed between the LGBP operations in which either the PA or the SSR participated.

METHODS

All patients undergoing LGBP between January 2007 and December 2009 in our prospectively collected bariatric database were reviewed. Demographics, baseline measures, intraoperative parameters, and outcomes were compared.

RESULTS

A total of 711 patients were identified. The group involving PAs included 343 patients, and the group involving SSRs included 368 patients. Preoperative comorbidities, including diabetes, hypertension, coronary artery disease, asthma, sleep apnea, hyperlipidemia, musculoskeletal disability, and depression, were similar in both groups. Personal histories of venous thromboembolism were higher in the PA group (5.1% vs 2.5%; P = .075). The mean body-mass indexes (BMI) (53 ± 9 vs 51 ± 8 kg/m(2); P = .006) and weights (323 ± 67 vs 306 ± 59 lbs; P < .001) in the PA group were significantly higher than in the SSR group. The proportion of males was higher in the PA group (24% vs 16%; P = .008). The operative time was significantly shorter in the PA group (121 ± 36 vs 164 ± 30 minutes; P < .001). There was no significant difference between the groups in intraoperative complications, length of hospital stay, 30-day complications, or reoperations within 1 year. There were no mortalities in either group. The 1-year percent excess weight loss (64% vs 66%) was similar in the PA and SSR groups, respectively.

CONCLUSION

SSR participation in LGBP prolongs operative time but does not increase complications, mortality rates, or length of stay. Therefore, SSR participation in LGBP is safe and produces outcomes comparable to those performed with PAs.

A pathway to endoscopic bariatric therapies

The American Society for Gastrointestinal Endoscopy (ASGE) is dedicated to advancing patient care and digestive health by promoting excellence in gastrointestinal endoscopy. The American Society for Metabolic and Bariatric Surgery (ASMBS) is dedicated to improving public health and well-being by lessening the burden of the disease of obesity and related diseases. They are the largest professional societies for their respective specialties of gastrointestinal endoscopy and bariatric surgery in the world. The ASGE/ASMBS task force was developed to collaboratively address opportunities for endoscopic approaches to obesity, reflecting the strengths of our disciplines, to improve patient and societal outcomes. This white paper is intended to provide a framework for, and a pathway towards, the development, investigation, and adoption of safe and effective endoscopic bariatric therapies (EBT).

Post-CCT National Surgical Fellowship in Bariatric and Upper GI Surgery

With fierce competition for the best consultant posts in surgery, a fellowship is almost becoming an essential requirement. There are numerous fellowships available but finding the right one and organising family life around it is extremely difficult. After a lot of scepticism from some trainees about the post-Certificate of Completion of Training (CCT) national surgical fellowships scheme, it was advertised in July 2008 through The Royal College of Surgeons of England in partnership with the surgical specialist associations. I was extremely fortunate to be successful in the interview in November 2008 as the first Fellow in Bariatric and Upper Gastrointestinal (GI) Surgery under the scheme and opted for the fellowship at Musgrove Park Hospital, Taunton, for one year.