Judgment Errors in Surgical Care

BACKGROUND

Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear.

STUDY DESIGN

The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression.

RESULTS

Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors.

CONCLUSIONS

Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.

Acute Respiratory Failure Complicating Endoscopic Sleeve Gastroplasty: A Case Report

Endoscopic sleeve gastroplasty (ESG) is a safe and minimally invasive procedure for the treatment of obesity. We report the case of a patient with obesity who underwent ESG complicated by postprocedural respiratory failure. During the procedure, she developed a Pao2/fraction of inspired oxygen (Fio2) ratio that necessitated postoperative mechanical ventilation. Chest radiography demonstrated massively dilated loops of bowel, cephalad displacement of both hemidiaphragms, lung volume reduction, and atelectasis. With absorption of luminal carbon dioxide, she was weaned from mechanical ventilation to supplemental oxygen, and she recovered completely. This case highlights postoperative respiratory failure associated with mechanical loading of the respiratory system following ESG.

Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers

BACKGROUND

Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention.

OBJECTIVES

The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons.

SETTING

Two mid-Atlantic quaternary care academic centers.

METHODS

Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05).

RESULTS

We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period.

CONCLUSIONS

RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization.

The impact of bariatric surgery on qualitative and quantitative breast density

BACKGROUND

Obesity and breast density are associated with breast cancer in postmenopausal women. Bariatric surgery effectively treats morbid obesity, with sustainable weight loss and reductions in cancer incidence. We evaluated changes in qualitative and quantitative density; hypothesizing breast density would increase following bariatric surgery.

METHODS

Women undergoing bariatric surgery from 1990 to 2015 were identified, excluding patients without a mammogram performed both before and after surgery. Changes in body mass index (BMI), time between mammograms and surgery, and American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) scores were assessed. VolparaDensity™ automated software calculated volumetric breast density (VBD), fibroglandular volume (FGV), and total breast volume for the 82 women with digital data available. Differences between pre- and postsurgery values were assessed.

RESULTS

One hundred eighty women were included. Median age at surgery was 50.0 years, with 8.8 months between presurgery mammogram and surgery and 62.3 months between surgery and postsurgery mammogram. Median BMI significantly decreased over the study period (46.0 vs 35.4 kg/m² ; P < 0.001). No change in BI-RADS scores was seen between the pre- and postsurgery mammograms. Eighty-two women had VolparaDensity™ data available. While VBD increased in these patients, FGV and total breast volume both decreased following bariatric surgery.

CONCLUSIONS

Increased VBD, decreased FGV, and decreased total breast volume were seen following bariatric surgery-induced weight loss. There was no difference in qualitative breast density, highlighting the discrepancy between BI-RADS and VolparaDensity™ measurements. Further investigation will be required to determine how differential changes in components of breast density may affect breast cancer risk.

Socioeconomically Distressed Communities Associated With Long-term Mortality After Bariatric Surgery

BACKGROUND

Surgical outcomes are affected by socioeconomic status, yet these factors are poorly accounted for in clinical databases. We sought to determine if the Distressed Communities Index (DCI), a composite ranking by zip code that quantifies socioeconomic risk, was associated with long-term survival after bariatric surgery.

METHODS

All patients undergoing Roux-en-Y gastric bypass (1985-2004) at a single institution were paired with DCI. Scores range from 0 (no distress) to 100 (severe distress) and account for unemployment, education, poverty, median income, housing vacancies, job growth, and business establishment growth. Distressed communities, defined as DCI ≥75, were compared with all other patients. Regression modeling was used to evaluate the effect of DCI on 10-year bariatric outcomes, whereas Cox Proportional Hazards and Kaplan-Meier analysis examined long-term survival.

RESULTS

Gastric bypass patients (n = 681) come from more distressed communities compared with the general public (DCI 60.5 ± 23.8 versus 50 ± 10; P < 0.0001). A total of 221 (32.3%) patients came from distressed communities (DCI ≥75). These patients had similar preoperative characteristics, including BMI (51.5 versus 51.7 kg/m²; P = 0.63). Socioeconomic status did not affect 10-year bariatric outcomes, including percent reduction in excess body mass index (57% versus 58%; P = 0.93). However, patients from distressed communities had decreased risk-adjusted long-term survival (hazard ratio, 1.38; P = 0.043).

CONCLUSIONS

Patients with low socioeconomic status, as determined by the DCI, have equivalent outcomes after bariatric surgery despite worse long-term survival. Future quality improvement efforts should focus on these persistent disparities in health care.

Resident-Specific Morbidity Reduced Following ACS NSQIP Data-Driven Quality Program

BACKGROUND

The Accreditation Council for Graduate Medical Education Milestone Project for general surgery provided a more robust method for developing and tracking residents' competence. This framework enhanced systematic and progressive development of residents' competencies in surgical quality improvement.

STUDY DESIGN

A 22-month interactive, educational program based on resident-specific surgical outcomes data culminated in a quality improvement project for postgraduate year 4 surgery residents. Self- assessment, quality knowledge test, and resident-specific American College of Surgeons National Surgical Quality Improvement Program Quality In-Training Initiative morbidity were compared before and after the intervention.

RESULTS

Quality in-training initiative morbidity decreased from 25% (82/325) to 18% (93/517), p = 0.015 despite residents performing more complex cases. All participants achieved level 4 competency (4/4) within the general surgery milestones improvement of care, practice-based learning and improvement competency. Institutional American College of Surgeons National Surgical Quality Improvement Program general surgery morbidity improved from the ninth to the sixth decile. Quality assessment and improvement self-assessment postintervention scores (M = 23.80, SD = 4.97) were not significantly higher than preintervention scores (M = 19.20, SD = 5.26), p = 0.061. Quality Improvement Knowledge Application Tool postintervention test scores (M = 17.4, SD = 4.88), were not significantly higher than pretest scores (M = 13.2, SD = 1.92), p = 0.12.

CONCLUSION

Sharing validated resident-specific clinical data with participants was associated with improved surgical outcomes. Participating fourth year surgical residents achieved the highest score, a level 4, in the practice based learning and improvement competency of the improvement of care practice domain and observed significantly reduced surgical morbidity for cases in which they participated.

Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study

Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m-2. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis (P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intraoperative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.

Roux-en-Y gastric bypass is safe in elderly patients: a propensity-score matched analysis

BACKGROUND

Numerous studies have established the effectiveness of Roux-en-Y gastric bypass (RYGB) for weight loss and co-morbidity amelioration. However, its safety and efficacy in elderly patients remains controversial.

OBJECTIVES

To evaluate outcomes in patients aged ≥60 years who underwent RYGB compared with nonsurgical controls with the hypothesis that RYGB provides weight loss benefits without differences in survival.

SETTING

University-affiliated tertiary center.

METHODS

All patients who underwent RYGB from 1985 to 2015 were identified and divided into elderly (age ≥60) and nonelderly (age <60) groups. A nonsurgical elderly control population was identified using a clinical data repository of outpatient visits to propensity match elderly patients 4:1 on demographic characteristics, co-morbidities, and relevant preoperative substance/medication use. Unpaired appropriate univariate analyses compared each stratified group. Kaplan-Meier survival curves were fitted based on social security death data.

RESULTS

A total of 2306 patients underwent RYGB. The 107 elderly patients had lower median body mass index (47.0 versus 49.9; P = .007) and higher rates of co-morbidities. Rates of complications did not differ between elderly and nonelderly patients. Elderly surgical patients were propensity matched 4:1 (10,044 controls) yielding 428 well-matched nonsurgical controls. The elderly group demonstrated significant percent reduction in excess body mass index compared with the control group (81.8% versus 10.3%; P < .001). Kaplan-Meier survival analysis with log-rank test demonstrated no difference in midterm survival (P = .63).

CONCLUSIONS

A significant weight reduction benefit was identified after RYGB in elderly patients without a difference in midterm survival compared with propensity-matched controls, suggesting RYGB is a safe and efficacious weight loss strategy in the elderly.

Patient Reported Outcomes 10 years After Roux-en-Y Gastric Bypass

BACKGROUND

Following weight-loss surgery, patients who failed to achieve or sustain weight loss have nevertheless reported high satisfaction with their long-term bariatric experience. Understanding this phenomenon better will likely improve patients' experiences.

OBJECTIVE

The purpose of this study was to explore patients' long-term experiences following bariatric surgery.

SETTING

A 604-bed academic health system in the USA.

METHODS

Participants rated satisfaction and shared spontaneous comments regarding their gastric bypass experience. A phenomenological mode of inquiry explored participants' experiences. Transcribed phrases were categorized and themes identified.

RESULTS

In a 2004 surgical cohort, with 55% (155/281) participation, 99% of participants rated bariatric experience satisfaction (mean score 8.4) and 74% (115/155) shared comments regarding experiences. Responses were categorized as positive (63% 72/115), neutral (25% 29/115), or negative (12% 14/115). Satisfaction, Appreciation, and Gratefulness emerged as themes from positive comments, with 8% (6/72) explicitly acknowledging amount of weight loss achieved. Twenty-five percent (18/72) spontaneously mentioned undergoing surgery again or recommending the procedure to others. Neutral comments contained the themes of Reflection, Acknowledgment, and Wistfulness. Themes of Dissatisfaction, Disappointment, and Regret emerged from negative comments. Forty-three percent (6/14) of negative comments remarked on regaining weight or not reaching goal weight. Twenty-one percent (3/14) of negative comments explicitly stated regret at having undergone surgery.

CONCLUSIONS

Participants readily shared comments regarding their gastric bypass experience. Exploring themes provided insight into patients' satisfaction with bariatric surgery even when weight-loss goals were not met and conversely substantial dissatisfaction even when weight loss occurred. This study underscores the importance of understanding the patients' long-term experience following bariatric surgery.

Benefit of feeding tube placement for refractory malnutrition after bariatric surgery

BACKGROUND

Bariatric surgery provides durable weight loss and decreases the incidence of co-morbid conditions for people with obesity. Most patients benefit from resultant weight loss, but some are at risk for postoperative refractory malnutrition, a serious but poorly understood complication.

OBJECTIVE

To evaluate differences in bariatric surgery patients who received a feeding tube postoperatively for malnutrition compared with other indications.

SETTING

Retrospective cohort study at an academic bariatric surgery center (1985-2015).

METHODS

All bariatric surgery patients that received a feeding tube postoperatively over a 30-year period were identified. Data abstraction from the medical record was performed to assess demographic characteristics, operative details, tube indication, and resultant body mass index (BMI) changes.

RESULTS

From a total of 3487 patients who underwent bariatric surgery during the study period, 139 (3.9%) required placement of a feeding tube postoperatively. Refractory malnutrition was the indication in 24 patients, all after Roux-en-Y gastric bypass. There were no significant differences between these patients and other bariatric surgery patients in terms of mean age (40.6±9.9 versus 43.1±13.4 years, P = .4) and preoperative BMI (47.5±10.5 versus 51.0±9.6 kg/m2, P = .1). The median time from surgery to tube placement for malnutrition patients was 4 years. Compared with other feeding tube indications, malnutrition patients had higher percent excess BMI lost after surgery (126.2±31.9 versus 52.5±44.3%, P<.0001). After tube placement, malnutrition patients had a significant increase in mean BMI compared with other indications (14.5±20.9 versus-13.0±14.0%, P< .001).

CONCLUSION

Patients with refractory malnutrition benefit from feeding tube placement, which results in a significant increase in BMI.

Using Interdisciplinary Workgroups to Educate Surgery Residents in Systems-Based Practice

BACKGROUND

Meaningful education of residents in systems-based practice is notoriously challenging, despite its recognition as 1 of the 6 Accreditation Council for Graduate Medical Education core competencies. To address this challenge, surgery residents and other members of the health care team were organized into interdisciplinary workgroups that were tasked with developing solutions to "systems issues" confronted on a daily basis. The project's goals included providing more meaningful, hands-on educational experience for residents in system-based practice, while also generating practical solutions to workflow issues through interprofessional collaboration.

PROJECT DESIGN

Project participants included all surgery residents at the University of Virginia in Charlottesville, VA, as well as surgical health care professionals across all disciplines. Participants were organized into workgroups. Over the course of 3 sessions, each of 1-hour, each workgroup identified commonly encountered systems issues, chose 1 issue to address, and determined an implementable solution for this issue. In total, 140 participants were divided among 13 workgroups.

PROJECT EXECUTION

Workgroup topics ranged from improving paging etiquette to standardizing interdisciplinary communication. In total, 9 of the 13 proposals have been piloted or fully implemented as standard practice at our institution, either within a single unit or over the entire health system.

DISCUSSION

This project demonstrates an innovative approach toward resident education in system-based practice, providing residents with a hands-on experience in problem solving from a systems perspective. These interdisciplinary workgroups generated effective solutions to issues that were meaningful to frontline health care providers. Interdisciplinary collaboration within the workgroups served as a valuable team-building exercise to improve relations between the disciplines. This project can serve as a model for other institutions desiring meaningful education in the Accreditation Council for Graduate Medical Education competency of systems-based practice.

Declining Operative Experience for Junior-Level Residents: Is This an Unintended Consequence of Minimally Invasive Surgery?

INTRODUCTION

Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior-level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve.

METHODS

A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried for these procedures between 2005 and 2012. Cases were stratified by participating resident post-graduate year with "junior resident" defined as post-graduate year1-3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time.

RESULTS

A total of 185,335 cases were included in the study. For 3 of the operations we considered, the prevalence of laparoscopic surgery increased from 2005-2012 (all p < 0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p = 0.119). Junior resident participation decreased by 4.5%/y (p < 0.001) for laparoscopic procedures and by 6.2%/y (p < 0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior-level residents decreased for appendectomy by 2.6%/y (p < 0.001) and cholecystectomy by 6.1%/y (p < 0.001), whereas it was unchanged for inguinal herniorrhaphy (p = 0.75) and increased for partial colectomy by 3.9%/y (p = 0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/y (p < 0.001), cholecystectomy by 4.1%/y (p < 0.002), inguinal herniorrhaphy by 10%/y (p < 0.001) and partial colectomy by 2.9%/y (p < 0.004).

CONCLUSIONS

Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior-level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education.

Roux-en-Y gastric bypass 10-year follow-up: the found population

BACKGROUND

The long-term durability of Roux-en-Y gastric bypass (RYGB) remains ill-defined in the American population secondary to poor follow-up after bariatric surgery.

OBJECTIVES

This study evaluated the population lost to follow-up to better define the long-term durability of RYGB for weight loss and co-morbidity amelioration.

METHODS

All patients (n = 1087) undergoing RYGB at a single institution between 1985 and 2004 were evaluated. Univariate differences in preoperative co-morbidities, postoperative complications, annual weight loss, and 10-year co-morbidities were analyzed to compare outcomes between patients with routine follow-up and those without. Using electronic medical record review for all encounters at our academic medical center and telephone survey, we obtained data for patients lost to follow-up.

RESULTS

Among 1087 RYGB patients, 151 (14%) had consistent 10-year follow-up in our prospectively collected database, with yearly clinic visits beyond 2 years postoperatively. Electronic medical record review and telephone survey data were collected on an additional 500 (46%) patients, resulting in 60% of patients having 10-year follow-up after RYGB. There was no statistical difference in any preoperative or postoperative variables between the 2 groups. We found no difference in co-morbidity prevalence preoperatively or at 10 years between groups. Examination of percent excess body mass index lost at yearly intervals revealed no difference between the groups at each interval up to 10 years (P = .36).

CONCLUSION

We found no difference in 10-year outcomes, including weight loss and co-morbidity reduction, between patients with routine clinic visits and those lost to follow-up. These 10-year data address the gap in knowledge resulting from poor long-term follow-up after bariatric surgery.

Gastric bypass improves survival compared with propensity-matched controls: a cohort study with over 10-year follow-up

BACKGROUND

The purpose of this study is to evaluate the long-term survival following gastric bypass using propensity-matched controls.

METHODS

We identified all patients who either received a gastric bypass (GBP) or met criteria to receive a GBP between January 1, 2002 and December 31, 2003. Propensity matching was performed. Long-term, all-cause mortality data were collected and evaluated using Kaplan-Meier curves.

RESULTS

Four hundred thirty GBP cases and 5,323 controls were identified from the enrollment period. Ultimately, 802 cases and controls (1:1 matching, 93.2% match rate) were identified using propensity matching. Median follow-up was similar between groups. Overall mortality was lower for the GBP group (odds ratio .48, 95% confidence interval .29 to .78). GBP demonstrated significantly increased survival when compared with controls (P = .002). Similar patterns were noted among diabetics.

CONCLUSION

We have demonstrated that gastric bypass provides a clear long-term survival advantage compared with nonsurgical propensity-matched controls.

Impact of Gastric Prolapse after Laparoscopic Adjustable Gastric Banding for Morbid Obesity

Gastric prolapse (GP) after laparoscopic adjustable gastric banding (LAGB) remains a complication that has the potential to result in significant morbidities. The purpose of this study was to evaluate the incidence of GP after LAGB and to determine its impact on patient outcomes among the morbidly obese. From 2005 to 2012, 379 consecutive morbidly obese patients underwent LAGB procedures at a single institution. Patients were placed into two groups based on the occurrence of gastric prolapse (GP vs no GP). Patient demographics and risk factors, operative features, and postoperative outcomes were analyzed by univariate analyses to assess the impact of GP. Average patient age was 47 ± 29 years and patients were commonly female (80%) with a median body mass index (BMI) of 44 kg/m2. Incidence of GP was 4.2 per cent (n = 16). LAGB median BMIs at 1 month and 1 year were 41 and 36 kg/m2. There was no difference in 1-year weight loss (BMI GP: 36 kg/m2 vs no GP: 36 kg/m2, P = 0.617). Laparoscopic gastric banding results in significant weight reduction and a low incidence of gastric prolapse. Gastric prolapse has no difference in 1-year postoperative median BMI when compared with patients who did not prolapse.

Impact of gastric prolapse after laparoscopic adjustable gastric banding for morbid obesity

Gastric prolapse (GP) after laparoscopic adjustable gastric banding (LAGB) remains a complication that has the potential to result in significant morbidities. The purpose of this study was to evaluate the incidence of GP after LAGB and to determine its impact on patient outcomes among the morbidly obese. From 2005 to 2012, 379 consecutive morbidly obese patients underwent LAGB procedures at a single institution. Patients were placed into two groups based on the occurrence of gastric prolapse (GP vs no GP). Patient demographics and risk factors, operative features, and postoperative outcomes were analyzed by univariate analyses to assess the impact of GP. Average patient age was 47 ± 29 years and patients were commonly female (80%) with a median body mass index (BMI) of 44 kg/m(2). Incidence of GP was 4.2 per cent (n = 16). LAGB median BMIs at 1 month and 1 year were 41 and 36 kg/m2. There was no difference in 1-year weight loss (BMI GP: 36 kg/m(2) vs no GP: 36 kg/m(2), P = 0.617). Laparoscopic gastric banding results in significant weight reduction and a low incidence of gastric prolapse. Gastric prolapse has no difference in 1-year postoperative median BMI when compared with patients who did not prolapse.

Twenty-first century weight loss: banding versus bypass

BACKGROUND

The two most commonly performed procedures for bariatric surgery include Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB). While many studies have commented on short-term, postoperative outcomes of these procedures, few have reported long-term data. The purpose of this study was to compare long-term, postoperative outcomes between RYGB and AGB.

METHODS

This was a retrospective, cohort comparing all patients undergoing RYGB or AGB at our institution, from 01/1998 to 08/2012. Patients were followed at 1-, 3-, and 5-year intervals. Adjusted, Cox proportional hazard regression and mixed effects repeated measures modeling were performed to generate cure ratios (CR) and 95 % confidence intervals (CI).

RESULTS

Two thousand four hundred twenty bariatric surgery patients (380 AGB, 2,040 RYGB) were identified by CPT code. Median (range) follow-up for patients was 3 (1-5) years. Preoperatively, RYGB patients were significantly younger, more obese, had higher hemoglobin A1c, and less often suffered from hypertension (HTN), dyslipidemia, and asthma as compared to AGB patients. Postoperatively, RYGB patients experienced significantly longer operating room times, higher incidences of intensive care unit admissions, longer hospital lengths of stay, and increased incidence of small bowel obstruction compared to AGB patients. After adjusting for statistically significant and clinically relevant factors [e.g., age, gender, body mass index, degenerative joint disease (DJD), diabetes, HTN, dyslipidemia, heart disease, apnea, and asthma], RYGB was independently associated with a significantly greater percentage of total body weight loss (p = 0.0065) and greater CR (95 % CI) regarding gastroesophageal reflux disease [2.1(1.4-3.0)], DJD [3.4(2.0-5.6)], diabetes [3.4(2.2-5.4)], apnea [3.1(1.9-5.3)], HTN [5.5(3.4-8.8)], and dyslipidemia [6.3(3.5-11)] compared to AGB.

CONCLUSION

Our results support previous studies that have observed a greater weight loss associated with RYGB as compared to AGB and provide further evidence toward the long-term sustainability of this weight loss. Additionally, RYGB appears to result in a greater reduction of medical comorbidity.

Long-term diabetic response to gastric bypass

BACKGROUND

As obesity and type II diabetes continue to rise, bariatric surgery offers a solution, but few long-term studies are available. The purpose of this study was to evaluate the long-term outcomes of diabetic patients after gastric bypass.

MATERIALS AND METHODS

This was a retrospective cohort study of all diabetic patients undergoing gastric bypass at our institution, from 1998 to 2012. Patients were compared by postoperative diabetic response to treatment (i.e., response = off oral medication/insulin versus refractory = on oral medication/insulin) and followed at 1-, 3-, 5-, and 10-y intervals. Continuous data were analyzed using Student t-test or Wilcoxon rank-sum test. Multivariable, Cox proportional hazard regression model was performed to compute diabetic cure ratios and 95% confidence intervals.

RESULTS

A total of 2454 bariatric surgeries were performed at our institution during the time period. A total of 707 diabetic patients were selected by Current Procedural Terminology codes for gastric bypass. Mean follow-up was 2.1 y. Incidence of diabetic response was 56% (1 y), 58% (3 y), 60% (5 y), and 44% (10 y). Postoperatively, responsive patients experienced greater percentage of total body weight loss (1 y [P < 0.0001], 3 y [P = 0.0087], and 5 y [P = 0.013]), and less hemoglobin A1c levels (1 y [P = 0.035] and 3 y [P = 0.040]) at follow-up than refractory patients. Multivariable analysis revealed a significant, independent inverse trend in incidence of diabetic cure as both age and body mass index decreased (Ptrend = 0.0019 and <0.0001, respectively). In addition, degenerative joint disease was independently associated with responsive diabetes (cure ratio = 1.6 [95% confidence interval = 1.1-2.2]).

CONCLUSIONS

At follow-up, both groups in our study experienced substantial weight loss; however, a greater loss was observed among the response group. Further research is needed to evaluate methods for optimizing patient care preoperatively and improving patient follow-up.

Surgical residency market research-what are applicants looking for?

OBJECTIVES

We propose that one of the integral parts of building a stronger residency program is the ability to recruit top applicants. Little is known about the factors applicants use to evaluate residency programs. Given that the top applicants are likely to be ranked highly by multiple programs, we sought to determine which factors applicants themselves used to evaluate potential residency programs.

DESIGN

An anonymous, voluntary survey was distributed to all interviewing applicants, asking them to rank 12 factors when choosing a residency. They were additionally asked about any prior research or international medical experience.

SETTINGS

Surveys were distributed at the beginning of the interview day and collected in sealed unmarked envelopes.

PARTICIPANTS

All applicants interviewing for general surgery residency at the University of Virginia during the 2009-2010 and 2010-2011 seasons.

RESULTS

Resident satisfaction was rated the highest, 8.7 out of 9. In descending order of importance, applicants ranked record of the chiefs (8.0), resident case volume (7.8), academic reputation (7.6), geography (7.4), research opportunities (7.3), laparoscopic laboratory (6.2), elective time (5.4), international opportunities (5.1), benefits (4.8), and vacation (4.7), respectively. No correlation was found between prior research experience and research ranking score. A significant positive correlation was found between those applicants with prior international experience and their ranking of international opportunities during residency (p < 0.0001).

CONCLUSIONS

Applicants rated a program on a broad range of factors and commonly cited a "gut feeling" or "esprit de corps." The ability to pursue an identified area of special interest, in this case an international opportunity, proved to be an additional major selection factor for a subset of candidates.

A comparative analysis between laparoscopic and open ventral hernia repair at a tertiary care center

Laparoscopic ventral hernia repair reportedly yields lower postoperative complications than open repair. We hypothesized that patients undergoing laparoscopic repair would have lower postoperative infectious outcomes. Also, certain preoperative patient characteristics and preoperative hernia characteristics are hypothesized to increase complication risk in both groups. All ventral hernia repairs performed at University of Virginia from January 2004 to January 2006 were reviewed. Primary outcomes included wound healing complications and hernia recurrence. Categorical data were analyzed with χ(2) and Fisher's exact tests. Continuous variables were evaluated with independent t tests and Mann-Whitney U tests. Multivariable logistic regression was performed. A total of 268 repairs (110 open, 158 laparoscopic) were evaluated. Patient and hernia characteristics were similar between groups, though the percents of wound contamination (5.4% vs 0.6%; P = 0.02) and simultaneous surgery (7.2% vs 0%; P = 0.001) were greater in the open procedures. Univariate analysis also revealed that open cases had a greater incidence of postoperative superficial surgical site infection (SSI) (30.0% vs 10.7%; P < 0.0001). Multivariable analysis revealed that both diabetes and open repair were associated with an increased risk of superficial SSI (P = 0.019; odds ratio = 3.512; 95% confidence interval = 1.229-10.037 and P = 0.001; odds ratio = 4.6; 95% confidence interval = 1.9-11.2, respectively). Laparoscopic ventral hernia repair yielded lower rates of postoperative superficial SSI than open surgery. Other preoperative patient characteristics and preoperative hernia characteristics, with the exception of diabetes, were not found to be associated with an increased risk of postoperative complications.

A Comparative Analysis between Laparoscopic and Open Ventral Hernia Repair at a Tertiary Care Center

Laparoscopic ventral hernia repair reportedly yields lower postoperative complications than open repair. We hypothesized that patients undergoing laparoscopic repair would have lower postoperative infectious outcomes. Also, certain preoperative patient characteristics and preoperative hernia characteristics are hypothesized to increase complication risk in both groups. All ventral hernia repairs performed at University of Virginia from January 2004 to January 2006 were reviewed. Primary outcomes included wound healing complications and hernia recurrence. Categorical data were analyzed with χ2 and Fisher's exact tests. Continuous variables were evaluated with independent t tests and Mann-Whitney U tests. Multivariable logistic regression was performed. A total of 268 repairs (110 open, 158 laparoscopic) were evaluated. Patient and hernia characteristics were similar between groups, though the percents of wound contamination (5.4% vs 0.6%; P = 0.02) and simultaneous surgery (7.2% vs 0%; P = 0.001) were greater in the open procedures. Univariate analysis also revealed that open cases had a greater incidence of postoperative superficial surgical site infection (SSI) (30.0% vs 10.7%; P < 0.0001). Multivariable analysis revealed that both diabetes and open repair were associated with an increased risk of superficial SSI ( P = 0.019; odds ratio = 3.512; 95% confidence interval = 1.229–10.037 and P = 0.001; odds ratio = 4.6; 95% confidence interval = 1.9–11.2, respectively). Laparoscopic ventral hernia repair yielded lower rates of postoperative superficial SSI than open surgery. Other pre-operative patient characteristics and preoperative hernia characteristics, with the exception of diabetes, were not found to be associated with an increased risk of postoperative complications.

The relationship between body mass index and 30-day mortality risk, by principal surgical procedure

OBJECTIVE

To examine the relationship between body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and 30-day mortality risk among patients in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program. Obesity is a prevalent chronic disease in the United States, and general and vascular surgeons are caring for an increasing population of obese patients.

DESIGN

Multivariable logistic regression analysis was used to assess the statistical significance of the relationship between BMI and mortality, with adjustments for patient-level differences in overall mortality risk and principal operating procedures. Odds ratios with 95% CIs were calculated to measure the relative difference in mortality by BMI quintile, with reference to the middle quintile of the BMI. The overall significance of the BMI and of the other covariates was measured using the Wald χ(2) test statistic. A separate multivariable logistic regression model was developed to assess the significance of the interaction between BMI and primary procedure.

SETTING

A total of 183 sites.

PATIENTS

Patients with major surgical procedures reported in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program.

RESULTS

The data included 189 533 cases of general and vascular surgical procedures reported in 2005 and 2006 for patients with known overall probabilities of death. Among these, 3245 patients died within 30 days of their surgery (1.7%). Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death, with 40% higher odds compared with patients in the middle range for BMI (26.3 to <29.7). Important differences in the association between BMI and mortality risk occur by type of primary procedure.

CONCLUSIONS

Body mass index is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death.

Percutaneous gastrostomy tube placement to perform transgastrostomy endoscopic retrograde cholangiopancreaticography in patients with Roux-en-Y anatomy

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery is one of the most commonly performed bariatric surgeries in the United States. Patients with prior RYGB are not amenable to conventional endoscopic retrograde cholangiopancreaticography (ERCP). Surgical gastrostomy (SG) tube placement enables transgastrostomy ERCP (TG-ERCP).

MATERIALS AND METHODS

Eleven patients with RYGB anatomy received open Stamm gastrostomy after which the tract was then allowed to mature for an average of 45 days before therapeutic TG-ERCP. The success rate and procedure-related complications of both gastrostomy and ERCP were assessed.

RESULTS

TG-ERCP was performed on eleven patients (median age 52 years, range 37-61 years) with prior RYGB and pancreatobiliary diseases. Indications for ERCP in these patients included suspected gallstone pancreatitis (n = 4), ampullary/biliary strictures (n = 5), pancreas divisum (n = 1), and common bile duct clipping as a result of RYGB surgery (n = 1). Two individuals developed post surgical complications with stomal-related infections. TG-ERCP with therapeutic intervention was successfully performed in all patients. Intervention included stone extractions (n = 11), biliary stricture dilation (n = 11), biliary sphincterotomy (n = 11), biliary (n = 3) and pancreatic (n = 1) stent placement, ampullary biopsies (n = 3), choledochoscopy (n = 1), and pseudocyst drainage (n = 1). Complications included post-ERCP pancreatitis (n = 2), post-sphincterotomy bleeding (n = 1), gastrostomy site bleed (n = 1), and gastric perforation (n = 1). The total number of ERCP sessions for the eleven patients was 15 (1 or 2 per patient). Median follow-up was 42 days (range 7-123 days).

CONCLUSION

Surgical open gastrostomy followed by TG-ERCP enables therapeutic intervention but is associated with significant complications.

Resident research forums stimulate novel research within general surgical training programs

BACKGROUND

Our surgery residency includes an annual Resident Research Day (RRD) for presentation of resident research. We hypothesized that RRD stimulates the development of novel research. We evaluated this among our residents and at other institutions.

STUDY DESIGN

An electronic survey was distributed to current and alumni residents at our institution. The survey questions addressed residents' perceptions of RRD and were graded on a 5-point Likert scale. Another electronic survey was distributed to Program Directors (PDs) or Associate Program Directors (APDs) for all U.S. general surgery residencies. Questions assessed type of RRD and impact on research productivity. Microsoft Excel (Microsoft Corporation, Redmond, Washington) and MedCalc (MedCalc Software, Inc, Mariakerke, Belgium) software were used for analyses.

RESULTS

The response rate was 76% (47/62) among residents and alumni. These 47 respondents submitted 98 projects to RRD, which included retrospective clinical studies (53%), basic science (35%), medical education research (6%), and prospective clinical papers (6%). Twenty projects (20%) were created expressly for RRD, of which 7 were presented at outside scientific meetings and 8 were published in peer-reviewed journals. The response rate was 47% among PD/APD (88/188). Most programs have an RRD or similar forum (78%) without difference between university and community programs (p = 0.78). Higher rates of resident submission were associated with dedicated research time for most residents (p = 0.01). Required submission was associated with novel projects created for RRD (p < 0.001). Thirty-seven percent of programs reported greater than 25% of submitted projects were created for RRD.

CONCLUSIONS

RRD and similar forums occur at most general surgery training programs. They stimulate research activity and satisfy most residents' expectations. RRD leads to completion of novel research projects that are presented both internally and in peer-reviewed form.

Quality of life and resolution of co-morbidities in super-obese patients remaining morbidly obese after Roux-en-Y gastric bypass

BACKGROUND

Not all patients undergoing Roux-en-Y gastric bypass with an initial body mass index (BMI) >50 kg/m(2) attain a BMI of <35 kg/m(2) postoperatively. We hypothesized that even though many of these patients remain morbidly obese after surgery, they still realize an improvement in co-morbidities and quality of life.

METHODS

Patients who had undergone Roux-en-Y gastric bypass and who had a preoperative BMI >50 kg/m(2) and postoperative BMI >35 kg/m(2) were identified. The records of 120 patients were reviewed for the presence of diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease. Patients were queried about their use of medications, medical problems, and quality of life.

RESULTS

The average preoperative and postoperative BMI was 63.2 and 43.7 kg/m(2). Of the 120 patients, 77 responded to the survey. In the preoperative group, the rate of diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease was 35%, 50.8%, 15%, and 34.2%, respectively. Postoperatively, 73.8%, 62.3%, 38.9%, and 87.8% of patients had been cured of these co-morbidities. The change in the incidence of diabetes, hypertension, and gastroesophageal reflux disease was significant at P = 0.0014, P = 0.037, and P <0.0001, respectively. More than 90% of patients considered themselves to be better postoperatively in the areas of overall health and ability to move about; 80-90% had improved ability to exercise, greater energy levels, more self esteem, and an improved physical appearance; 70-80% saw their ability to work and their social relationships as improved; and 56% believed their sexual relationships had improved.

CONCLUSION

Super-obese patients experience significant improvements in co-morbidities and quality of life after Roux-en-Y gastric bypass even if their BMI remains >35 kg/m(2).

The effect of a low-carbohydrate, high-protein diet on post laparoscopic gastric bypass weight loss: a prospective randomized trial

BACKGROUND

Laparoscopic gastric bypass has become the standard surgical treatment for severe obesity in the United States. Less clear is what diet should be followed by these patients after surgery to maximize their weight loss.

METHODS

Patients undergoing laparoscopic gastric bypass procedures for morbid obesity were randomly assigned to either a low-fat control diet based on American Heart Association recommendations or a low-carbohydrate, high-protein diet based on the South Beach Diet. One-on-one diet counseling with a bariatric nutritionist was provided preoperatively, postoperatively while in the hospital, and at postoperative clinic visits during the 12-month follow-up period. Investigators were blinded to diet assignment. Body composition including Body Mass Index (BMI) was recorded preoperatively and during postoperative visits at 3, 6, and 12 months.

RESULTS

Thirty-two patients were included in the analysis with 13 control and 19 low-carbohydrate, high-protein subjects. No demographic or clinical preoperative variables, including preoperative BMI, showed statistical differences between the two groups. Both groups demonstrated significant yet similar weight loss both by reduction in BMI (at 12 months, low fat diet, -14.0 +/- 5.5% versus low carbohydrate, -17.0 +/- 4.5%; P = 0.15) and excess body weight lost (at 12 months, low-fat diet, -60.3 +/- 15.3% versus low carbohydrate, -59.6 +/- 13.0%; P = 0.96).

CONCLUSIONS

Based on this limited prospective study, no weight loss advantage is observed in substituting a low-carbohydrate, high-protein diet in place of a standard low-fat diet in patients who have undergone laparoscopic gastric bypass surgery.

Bariatric surgery training: getting your ticket punched

Laparoscopic bariatric surgery has gained popularity but has been proven to be a technically challenging set of operations that requires a long learning curve. Trainees must acquire advanced laparoscopic skills and knowledge of the perioperative care of the bariatric patient. The challenge is to ensure that those surgeons performing gastric bypass, gastric banding, and duodenal switch procedure are trained appropriately. In the past, very different opportunities have been available for the general surgeon seeking to practice bariatric surgery. Early on, many surgeons began performing bariatric surgery without any formal training. Later, weekend courses, mini-fellowships, and formal minimally invasive surgery/bariatric fellowships were established. Today, best practice requires an intensive training experience and ongoing commitment to the field.

Does enteral glutamine supplementation decrease infectious morbidity?

BACKGROUND

Although some studies have demonstrated lower infectious morbidity in patients receiving supplemental glutamine, there remains no consensus on the utility of such treatment. This study was designed to investigate the effects of supplemental enteral glutamine on the rate and outcomes of infection in critically ill surgical patients.

METHODS

All 185 surgical and trauma patients admitted to a single university surgical trauma intensive care unit (STICU) over an approximately three-year period who were to receive enteral nutrition support were assigned sequentially to one of three diets: standard 1-kCal/mL feedings with added protein (Group 1), standard feedings with glutamine 0.6 g/kg per day (Group 2), or immune-modulated feedings with a similar amount of glutamine (Group 3). Group compositions and patient characteristics were similar at baseline. Data were collected prospectively on infections acquired during hospitalization.

RESULTS

A total of 119 patients had at least one infection: 59% of the patients in Group 1, 64% of Group 2, and 69% of Group 3 (p = NS). There were no differences among the groups in the mean number of infections. The most common sites in all groups were the lungs, blood, and urine; and the frequencies of these infections did not differ between groups. Minor differences were found between groups in the organisms isolated. Antibiotic usage did not differ.

CONCLUSION

Supplemental enteral glutamine in the dose studied does not appear to influence the acquisition or characteristics of infection in patients admitted to a mixed STICU.

Remediation of low ABSITE scores

PURPOSE

In 2000, a program was initiated to improve American Board of Surgery In-Training Exam (ABSITE) scores below the 40th percentile (PGY-1 and -2) and the 30th percentile (PGY-3 and -5) for categorical residents. The goal of this program is to maintain scores above this standard.

METHODS

One faculty member was designated to meet with each resident with ABSITE scores below the standard described above. In April, individual study plans were designed with each resident, which emphasized practice questions and strategic planning for study, and the ABSITE test structure and results were reviewed. Two subsequent meetings were held between November and December to monitor progress. Emphasis was placed on minimizing the stigma of poor scores and on maximizing the efficiency of study time. If the resident scored above-standard that year, further support was not required.

RESULTS

From 2000 to 2004, 12 (9.5%) ABSITE scores were below-standard, which resulted in 8 (20.5%) residents receiving program support 9 times. All but 1 program encounter resulted in above-standard scores the following year (improvement range, 16 to 65 percentile points; average, 34 points). Two residents had recurrent below-standard scores in subsequent years despite above-standard scores immediately after the program. One resident did not participate in the program, despite it being designated as mandatory. During the same interval, the ABSITE scores of residents not involved in the program decreased by an average of 3.7 percentile points per examination (improved scores 31 times; 39.2%, range 1 to 46, average 13.5, worse scores 45 times; 57%, range 1 to 65, average 15.2, and no change 3 times, 3.8%).

CONCLUSIONS

An individualized program that minimizes the stigma of poor test results, the time commitment required by the residents, and maximizes the benefits of a question-based study system and the knowledge of approach to the ABSITE resulted in significant improvements in scores the next year. However, maintenance of these results needs continued evaluation because 3 residents had recurrent poor scores in subsequent years.

Does the addition of glutamine to enteral feeds affect patient mortality?

OBJECTIVE

Studies have failed to consistently demonstrate improved survival in intensive care unit (ICU) patients receiving immune-modulating nutrient-enhanced enteral feeds when compared with standard enteral feeds. The objective was to study in a prospective fashion the effects of adding glutamine to standard or immune-modulated (supplemented with omega-3 fatty acids, beta-carotene, and amino acids such as glutamine and arginine) tube feeds.

DESIGN

Prospective, unblinded study using sequential allocation.

SETTING

A university surgical trauma ICU.

PATIENTS

All surgical and trauma patients admitted to the surgical trauma ICU at a university hospital over a 3-yr period who were to receive enteral feeds (n = 185).

INTERVENTIONS

Sequential assignment to three isocaloric, isonitrogenous diets was performed as follows: standard 1-kcal/mL feeds with added protein (group 1), standard feeds with the addition of 20-40 g/day (0.6 g/kg/day) glutamine (group 2), or an immune-modulated formula with similar addition of glutamine (group 3). The goal for all patients was 25-30 kcal/kg/day and 2 g/kg/day protein.

MEASUREMENTS AND MAIN RESULTS

Patients were followed until discharge from the hospital. The primary end point was in-hospital mortality, and multiple secondary end points were recorded. In-hospital mortality for group 1 was 6.3% (four of 64) vs. 16.9% (ten of 59, p = .09) for group 2 and 16.1% (ten of 62, p = .09) for group 3. After controlling for age and severity of illness, the difference in mortality between patients receiving standard tube feeds and all patients receiving glutamine was not significant (p < or = .11). There were no statistically significant differences between the groups for secondary end points.

CONCLUSIONS

The addition of glutamine to standard enteral feeds or to an immunomodulatory formula did not improve outcomes. These findings suggest that enteral glutamine should not be routinely administered to patients with surgical critical illness.

Cholelithiasis and cholecystitis

Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.

A nutrition support team led by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service

The purpose of this study was to decrease the number of inappropriate orders for total parenteral nutrition (TPN) in surgical patients. From February 1999 through November 2000 and between July 2001 and June 2002, the surgeon-guided adult nutrition support team (NST) at a university hospital monitored new TPN orders for appropriateness and specific indication. In April 1999, the NST was given authority to discontinue inappropriate TPN orders. Indications, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, included short gut, severe pancreatitis, severe malnutrition/catabolism with inability to enterally feed > or =5 days, inability to enterally feed >50 per cent of nutritional needs > or =9 days, enterocutaneous fistula, intra-abdominal leak, bowel obstruction, chylothorax, ischemic bowel, hemodynamic instability, massive gastrointestinal bleed, and lack of abdominal wall integrity. The number of inappropriate TPN orders declined from 62/194 (32.0%) in the first 11 months of the study to 22/168 (13.1%) in the second 11 months (P < 0.0001). This number further declined to 17/215 (7.9%) in the final 12 months of data collection, but compared to the second 11 months, this decrease was not statistically significant (P = 0.1347). The involvement of a surgical NST was associated with a reduction in inappropriate TPN orders without a change in overall use.

Comparing resident measurements to attending surgeon self-perceptions of surgical educators

OBJECTIVE

The purpose of this study was to evaluate the initiation and utility of evaluating attending surgeons as educators by resident trainees. Additionally, we were interested in comparing resident measurements to attending self-perceptions.

METHODS

A written evaluation form, (utilizing five-point ordinal scale assignments) queried respondents regarding the performance of surgical attendings in the operating room, and other clinical settings. A similar form was distributed to the faculty members, which they used to evaluate themselves. Mean scores were determined, as were comparisons between self-perception and resident assessments. Differences in scores with p values less than 0.05 were considered statistically significant.

RESULTS

Thirty-six residents evaluated 23 attendings. Mean assignments by residents of performance in the operating room, other clinical settings, and overall scores for all faculty members as a group were 4.22 +/- 0.04, 4.11 +/- 0.03, and 4.16 +/- 0.03, respectively, with a score of five, generally corresponding to a most favorable rating. When overall scores were analyzed, 10 attendings received scores that differed significantly from those received by their peers, with half of subjects above, and the other half being below the 95% confidence interval. Eighteen (78%) of attendings completed the self-evaluation forms, and of these, 11 (61%) had self-perceptions that differed significantly from overall scores as reported by the residents.

CONCLUSIONS

Our evaluation process delineated significant differences among attending faculty members and identified individual strengths and weaknesses. Many educators' self-perceptions differed significantly from resident assessments, and attendings who did not evaluate themselves scored lower than their peers.

Comparing resident measurements to attending surgeon self-perceptions of surgical educators

OBJECTIVE

The purpose of this study was to evaluate the initiation and utility of evaluating attending surgeons as educators by resident trainees. Additionally, we were interested in comparing resident measurements to attending self-perceptions.

METHODS

A written evaluation form, (utilizing five-point ordinal scale assignments) queried respondents regarding the performance of surgical attendings in the operating room, and other clinical settings. A similar form was distributed to the faculty members, which they used to evaluate themselves. Mean scores were determined, as were comparisons between self-perception and resident assessments. Differences in scores with p values less than 0.05 were considered statistically significant.

RESULTS

Thirty-six residents evaluated 23 attendings. Mean assignments by residents of performance in the operating room, other clinical settings, and overall scores for all faculty members as a group were 4.22 +/- 0.04, 4.11 +/- 0.03, and 4.16 +/- 0.03, respectively, with a score of five, generally corresponding to a most favorable rating. When overall scores were analyzed, 10 attendings received scores that differed significantly from those received by their peers, with half of subjects above, and the other half being below the 95% confidence interval. Eighteen (78%) of attendings completed the self-evaluation forms, and of these, 11 (61%) had self-perceptions that differed significantly from overall scores as reported by the residents.

CONCLUSIONS

Our evaluation process delineated significant differences among attending faculty members and identified individual strengths and weaknesses. Many educators' self-perceptions differed significantly from resident assessments, and attendings who did not evaluate themselves scored lower than their peers.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway

OBJECTIVE

To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization.

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied.

METHODS

During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared.

RESULTS

After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings.

CONCLUSIONS

Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.