Does Certification as Bariatric Surgery Center and Volume Influence the Outcome in RYGB—Data Analysis of German Bariatric Surgery Registry

Obesity Surgery and the Treatment of Metabolic Diseases

BACKGROUND

3.9% of men and 5.2% of women in Germany suffer from second-degree obesity (body mass index [BMI] ≥ 35 to <40 kg/m2), and 6.5 million persons suffer from diabetes. Obesity surgery has become established as a further treatment option alongside lifestyle changes and pharmacotherapy.

METHODS

The guideline was created by a multidisciplinary panel of experts on the basis of publications retrieved by a systematic literature search. It was subjected to a formal consensus process and tested in public consultation.

RESULTS

The therapeutic aims of surgery for obesity and/or metabolic disease are to improve the quality of life and to prolong life by countering the life-shortening effect of obesity and its comorbidities. These interventions are superior to conservative treatments and are indicated when optimal non-surgical multimodal treatment has been tried without benefit, in patients with BMI ≥ 40 kg/m², or else in patients with BMI ≥ 35 kg/m² who also have one or more of the accompanying illnesses that are associated with obesity. A primary indication without any prior trial of conservative treatment exists if the patient has a BMI ≥ 50 kg/m², if conservative treatment is considered unlikely to help, or if especially severe comorbidities and sequelae of obesity are present that make any delay of surgical treatment inadvisable. Metabolic surgery for type 2 diabetes is indicated (with varying recommendation grades) for patients with BMI ≥ 30 kg/m², and as a primary indication for patients with BMI ≥ 40 kg/m². The currently established standard operations are gastric banding, sleeve gastrectomy, proximal Roux-en-Y gastric bypass, omega-loop gastric bypass, and biliopancreatic diversion.

CONCLUSION

No single standard technique can be recommended in all cases. In the presence of an appropriate indication, the various surgical treatment options for obesity and/or metabolic disease should be discussed with the patient.

Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters

BACKGROUND

Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia.

METHODS

We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared.

RESULTS

During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001).

CONCLUSION

Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.

The effect of surrogate procedure volume on bariatric surgery outcomes: do common laparoscopic general surgery procedures matter?

BACKGROUND

A growing body of evidence shows that experience and acquired skills from surrogate surgical procedures may be transferrable to a specific index operation. It is unclear whether this applies to bariatric surgery. This study aims to determine whether there is a surrogate volume effect of common laparoscopic general surgery procedures on all-cause bariatric surgical morbidity.

METHODS

This was a population-based study of all patients aged ≥ 18 who received a bariatric procedure in Ontario from 2008 to 2015. The main outcome of interest was all-cause morbidity during the index admission. All-cause morbidity included any documented complication which extended length of stay by 24 h or required reoperation. Bariatric cases included laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. Non-bariatric cases included three common laparoscopic general surgery procedures.

RESULTS

13,836 bariatric procedures were performed by 29 surgeons at nine centers of excellence. A reduction in all-cause morbidity was seen when bariatric surgeons exceeded 75 cases annually (OR 0.82, 95% CI 0.69-0.98, P = 0.023), with further reduction in increasing bariatric volume. However, the volume of non-bariatric surgeries did not significantly affect bariatric all-cause morbidity rates amongst bariatric surgeons, even when exceeding 100 cases (OR 0.84, 95% CI 0.61-1.12, P = 0.222).

CONCLUSIONS

The present study suggests that experience and skills acquired in performing non-bariatric laparoscopic general surgery does not appear to affect all-cause morbidity in bariatric surgery. Therefore, only a surgeon's bariatric procedure volume should considered be a quality marker for outcomes after bariatric surgery.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project

INTRODUCTION

There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems.

METHODS

The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries.

RESULTS

The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center.

CONCLUSION

Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

[Barriers to the German Society for General and Visceral Surgery (DGAV) accreditation "Center for bariatric and metabolic surgery"]

INTRODUCTION

The certification and accreditation process of the German Society for General and Visceral Surgery (DGAV) aims to improve the quality of care and enhance transparency in accredited centers. To achieve these goals a high level of infrastructural and staffing requirements are set out by the DGAV.

AIMS

The Surgical Working Group on Obesity Treatment and Metabolic Surgery (CAADIP) survey 2017 of the members of the German Bariatric Society aimed to identify the perceived and encountered barriers in the DGAV accreditation process.

METHODS

Between February and March 2017 an online poll was conducted of all members of the CAADIP on topics pertaining to the accreditation process.

RESULTS

A total of 214 (51%) CAADIP members participated in the poll, 47% reported that they worked at a non-certified center and 53% worked at a DGAV certified center. Of these, 68% reported employment in a unit with the lowest accreditation level, 21% in an intermediate level center, 11% reported employment in a unit with the highest accreditation level (Center of Excellence) and 86% of those currently working in non-accredited units stated that they aimed for future accreditation. Reasons stated for not having obtained accreditation were recent establishment of the new bariatric specialty (54%), lack of bariatric case numbers (71%), lack of human resources and infrastructure (28% and 13%, respectively). Of those surgeons in non-accredited centers 24% stated that the hospital management had no interest in a certification and 12% of the surgeons themselves felt that accreditation was unnecessary.

CONCLUSION

The majority of CAADIP members strived for DGAV certification. The main barriers encountered and perceived were the specific time (reference years) and caseload requirements.

Comparison of Outcomes in Below-Knee Amputation between Vascular and General Surgeons

BACKGROUND

There is evidence to suggest outcomes may be related to surgeon experience or skill level. Lower extremity amputations are performed by both general surgeons (GSs) and vascular surgeons (VSs); however, the effect of specialty on postoperative outcome in below-knee amputation is not known. This retrospective study compares outcomes in below-knee amputations (BKA) between VS and GS.

METHODS

Patients who underwent below-knee amputations between 2005 and 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Project database. Data collected included patient demographics, comorbid conditions, and indication for procedures. Univariate and multivariate unconditional logistic regression models and linear regression models were employed to evaluate the associations between various outcomes and indications for surgery, emergency and teaching status, and surgical specialty.

RESULTS

Amputations performed by GSs experienced an increased risk of developing pneumonia (odds ratio [OR] = 1.49, 95% confidence interval [CI]: 1.19-1.86), pulmonary embolism (OR = 2.10, 95% CI: 1.10-4.01), and sepsis (OR = 1.29, 95% CI: 1.05-1.59). When stratified by indications for BKA, similar outcomes were noted between GS and VS if indication for surgery was diabetes or peripheral vascular disease; however, there was increased risk of pneumonia (OR = 1.86, 95% CI: 1.26-2.74), sepsis (OR = 1.96, 95% CI: 1.39-2.75), and death (OR = 1.47, 95% CI: 1.04-2.07, P = 0.027) when GS performed BKA for infectious indications. Overall complications were higher when GS performed BKA emergently (OR = 1.17, 95% CI: 1.01-1.36).

CONCLUSION

There are less postoperative complications when VSs performed BKA for infectious indications, during emergencies, and at nonteaching hospitals. Clinicians should consider vascular consultation for these specific scenarios.

Bariatric Surgery Registries: Can They Contribute to Improved Outcomes?

PURPOSE OF REVIEW

Clinical registries systematically collect prospective information about patients with a particular medical condition, who have had a medical device implanted or who have undergone a particular procedure. When these variables are collected with pre-defined quality indices included, the benched-marked risk-adjusted data may be a valuable resource for providing feedback on outcomes, including performance, to practitioners, patients, health services and device manufacturers.

RECENT FINDINGS

There are examples of feedback from clinical registries positively influencing patient care. The Australian National Joint Registry identified a poorly performing hip prosthesis which was ultimately withdrawn from the market. Feedback from the Victorian State Prostate Cancer Registry has contributed to improved patient care and fewer positive surgical margins noted over a 5-year reporting period. There are several national and regional registries collecting information on patients undergoing bariatric surgery, however, few currently focus on quality outcome measures. Whilst, current bariatric registries have contributed to improved understanding of some of the clinical situations relating to bariatric surgery, as well as developing composite risk scores and measuring quality cultures, they have not as yet demonstrably directly influenced patient care. This may reflect the fact that many of the registries do not hold data that are mature enough for proper analysis, but may also reflect problems with systematic data collection, bias from missing results and lack of appropriate funding. It will be important in the future that bariatric surgery registries actively seek to measure and validate their contribution to patient outcomes.