A Two-Consultant Approach is a Safe and Efficient Strategy to Adopt during the Learning Curve for Laparoscopic Roux-en-Y Gastric Bypass: Our Results in the First 100 Procedures

Learning Curves of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Bariatric Surgery: a Systematic Review and Introduction of a Standardization

BACKGROUND

The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG.

METHODS

A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected.

RESULTS

A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery.

CONCLUSIONS

Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.

Mentorship Programs in Bariatric Surgery Reduce Perioperative Complication Rate at Equal Short-Term Outcome-Results from the OPTIMIZE Trial

OBJECTIVES

The aim of this study was to determine the efficacy of coaching on outcome in low volume centers of excellence and to evaluate the influence of mentorship programs on the center development.

BACKGROUND

The number of bariatric procedures has increased steadily in the last years. Providing nationwide bariatric care on a high professional level needs structures to train and guide upcoming centers and ensure high quality in patient care.

METHODS

A prospective multicentered, observational study including laparoscopic sleeve gastrectomies (SG) and Roux-en-Y gastric bypass (RYGB) procedures was performed. Twelve emerging bariatric centers were coached by five experienced bariatric centers. Surgeons of the mentor centers gave guidance on pre- and postsurgical management of their patients including complications and proctored the first interventions. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, and resolution of comorbidities.

RESULTS

A total of 214 of 293 patients (73.0%) completed the study. The most frequently reported complications were wound infection (4.4%), disorder of emptying stomach/new reflux (2.4%), anastomotic leaks, intra-abdominal secondary hemorrhage, and dumping syndrome (2.0% each). The mortality rate was zero. We found no difference in overall complication rates or resolution of obesity-related comorbidities when comparing experienced surgeons with less experienced surgeons.

CONCLUSIONS

Our results suggest that under the conditions of the practices of this study, coaching and mentoring were associated with comparable outcomes both in experienced and emerging centers. In addition, mentorship programs ensure equal outcome quality in terms of improvement of obesity-associated comorbidities.

TRIAL REGISTRATION

NCT Number: NCT01754194 .

Bariatric fellowship positively influences early outcomes for laparoscopic Roux-en-Y gastric bypass surgery over seven years of independent practice

Introduction Laparoscopic Roux-en-Y gastric bypass (LRYGB) is technically demanding and has an associated learning curve. We published previously that bariatric fellowship reduces the learning curve of primary LRYGB and improves patient outcomes after one year of independent practice. However, the long-term effect of fellowship is unknown. We therefore aimed to compare the 30-day outcomes of LRYGB between the first year of a surgeon's independent practice with the subsequent six years. Materials and methods A prospective database of patients undergoing primary LRYGB under a single surgeon from March 2010 until February 2017 was analysed. Two groups were studied: first year (< 1 year) and the subsequent six years (≥ 1 year) of independent practice. Patient demographics, length of hospital stay, conversion to open surgery, perioperative complications and mortality were compared. Results Among 279 eligible patients, 74 (26.5%) were in the < 1 year group and 205 (73.5%) in ≥ 1 year group. The preoperative risk scores, American Society of Anesthesiologists (ASA) grade, P = 0.00; obesity surgery mortality risk score (OS-MRS), P = 0.04) were significantly higher in ≥ 1 year group. There was no significant difference in perioperative outcomes (length of stay, P = 0.38; total complications, P = 0.20; readmissions, P = 1.00; reoperations, P = 0.60) between the two groups. Conclusions Bariatric fellowship reduces the learning curve for LRYGB and helps to achieve excellent outcomes in the first and subsequent years of independent practice. The higher risk profile of ≥ 1 year group did not equate to an increase in complications, suggesting that experience and standardisation may help in handling complex cases. To our knowledge, this represents the only such study in the literature.

A survey of current controversies in scoliosis surgery in the United Kingdom

STUDY DESIGN

A 10-point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery, such as choice of implant, bone graft, autologous blood transfusion, cord monitoring, and computer-assisted surgery. Comparisons were then made with recommendations published in the spinal literature.

OBJECTIVE

To determine certain aspects of the current practice of scoliosis surgery in the United Kingdom.

SUMMARY OF BACKGROUND DATA

Guidelines for good clinical practice in spinal deformity surgery are available in the United Kingdom but do not cover a number of controversial issues.

METHODS

Consultants and fellows attended the 2009 British Scoliosis Society meeting. Fifty questionnaires were completed by 45 consultants and 5 fellows.

RESULTS

All pedicle screw constructs favored by 25 of 50, hybrid 24 of 50 (1 undecided). Posterior construct of fewer than 10 levels, 20 of 50 would not cross-link, 11 of 50 used 1, and 19 of 20 used 2 or more. More than 10 levels 17 of 50 considered cross-links unnecessary, 4 of 50 used 1 and 29 of 50 used 2 or more. Eighty-eight percent preferred titanium alloy implants, whereas others used a mixture of stainless steel and cobalt chrome. When using bone graft, respondents used bone substitutes (24), iliac crest graft (14), allograft (12) and demineralized bone matrix (9) in addition to local bone. Ten of 50 would use recombinant bone morphogenetic protein (3 for revision cases only). Thirty-nine of 50 routinely used intraoperative cell salvage and 4 of 50 never used autologous blood. All used cord monitoring: sensory (19 of 50), motor (2 of 50), and combined (29 of 50). None used computer-aided surgery. Twenty-six operated alone, 12 operated in pairs, and 12 varied depending on type of case.

CONCLUSION

This survey shows interesting variations in scoliosis surgery in the United Kingdom. It may reflect the conflicting evidence in the literature.

Training programs influence in the learning curve of laparoscopic gastric bypass for morbid obesity: a systematic review

The makeup of a new surgical bariatric team may be associated with a higher number of postoperative complications due to the learning curve. The aim of this study was to evaluate the outcomes during the learning curve of laparoscopic gastric bypass (LGBP) depending on surgeons' training. A systematic approach was used to review studies from the Pubmed, Embase (Ovid), Cancer Lit, Biomes Central via Scirus, Current Contens (ISI), and Web of Science (SCI) databases. Two reviewers independently screened all titles/abstracts and included/excluded studies based on full copies of manuscripts. The outcomes included were: specific training of the surgeon, postoperative complications (leaks, occlusion, hemorrhage, pneumonia, etc.), mortality, and surgical technique. One reviewer put data onto an Excel spreadsheet. Statistical analysis was performed with weighted linear regression. We identified 448 citations, of which 120 abstract and 50 full-text publications were reviewed. Fourteen papers were selected. Data from 1,848 patients were included. Eighteen different surgeons were analyzed during their learning curve (including the first author of this study). Surgeons were divided into two groups: (1) without formal laparoscopic bariatric training (13 surgeons) and (2) with formal laparoscopic bariatric training (five surgeons). Postoperative complications were more frequent in group 1: 18.1% (± 7.6) vs. 7.7% (± 1.96, p = 0.046); also, mortality was more frequent in group 1: 0.57% (± 0.87) vs. 0% (p = 0.05). An appropriated training in laparoscopic bariatric surgery contributes to a significant reduction in postoperative complications and mortality during the learning curve of LGBP.

Four hundred fifty consecutive laparoscopic Roux-en-Y gastric bypasses with no mortality and declining leak rates and lengths of stay in a bariatric training program

BACKGROUND

We reviewed our obesity surgery database for 2 experienced bariatric surgeons since their last patient death in October 2003 through July 2007.

STUDY DESIGN

Data on all patients undergoing planned laparoscopic Roux-en-Y gastric bypass (L-GBP) by the two attending bariatric surgeons at the Medical College of Virginia Hospitals were reviewed. The operations were performed by fellows in minimally invasive surgery, assisted by the 2 attending physicians in more than 90% of patients. Surgical technique included a handsewn imbrication of a gastrojejejunostomy and jejunojejunostomy, each performed with a linear stapler. Routine sampling of a juxtaanastamotic drain for amylase levels was substituted for routine upper gastrointestinal contrast studies during the study period.

RESULTS

All patients, except those who had earlier extensive upper abdominal surgery in that time period, were offered a laparoscopic approach (5.7% were converted to open procedures). The mean (+/- SD) age was 42.4+/-11 years; body mass index was 49.5+/-9 kg/m(2). Women represented 80.5% of patients. The leak rate declined from 9.7% in 2004 to 2.0% in 2006 (p < 0.05, chi-square test); there have been no leaks in any patient since July 2006, including the 40 patients in 2007. Hospital length of stay declined from 4.7+/-5.7 days in 2004 to 2.9+/-3.3 days in 2006 (p < 0.05, Wilcoxon rank test). At 1-year followup, 270 patients had lost 66.1%+/-17% of initial excess weight, which was similar to that in our open gastric bypasses. Comorbid conditions improved or resolved in 67.6% of patients with diabetes, 56.1% of those with hypertension, 75% of those with sleep apnea, 87.8% of those with urinary stress incontinence, 95.9% of those with gastroesophageal reflux disease, and in 100% of those with stasis ulcers. Overall complication rates of wound infection (1.5%), incisional hernia (1.7%), internal hernia (0.2%), and intestinal obstruction (1.7%) were low.

CONCLUSIONS

Results for laparoscopic Roux-en-Y gastric bypass improve with experience and can be taught in an academic training program, with low morbidity and mortality. Routine postoperative upper gastrointestinal contrast studies are unnecessary and may lengthen hospital stay.