Impact of Fellowship Training on the Learning Curve for Laparoscopic Gastric Bypass

Background: We have previously shown that the learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGBP) is approximately 75 cases. Patients have worse outcomes during the learning curve. Our aim was to evaluate the impact of fellowship training on outcomes during a surgeon's early experience with LRYGBP. Methods: The study population consisted of the first 75 consecutive LRYGBP operations attempted by two laparoscopic surgeons, one with laparoscopic gastric bypass fellowship training (Group A) and one without laparoscopic bypass fellowship training (Group B). Outcome parameters included mortality, major perioperative complications, operative time, and conversion to an open operation. Results: Age, BMI, and gender distribution were similar in both groups. Operative time was significantly longer in Group B (189 min. vs 122 min., P <0.05). Conversion to an open procedure occurred uncommonly in both groups (3%). Major complications occurred more frequently in Group B (13% vs 8%, P =NS). In addition, the complications in Group B were more severe, resulting in 2 deaths. No deaths occurred in Group A. Conclusion: Laparoscopic gastric bypass fellowship training improves perioperative outcomes during a surgeon's early experience with LRYGBP.     

Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass

Background  

The concept that advanced surgical training can reduce or eliminate the learning curve for complex procedures makes logical sense but is difficult to verify and has not been tested for laparoscopic Roux-en-Y gastric bypass (LRYGB). We sought to determine if minimally invasive/bariatric surgery fellowship graduates (FGs) would demonstrate complication-related outcomes (CRO) equivalent to the outcomes achieved during their training experience under the supervision of experienced bariatric surgeons.     

Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass

Background The reported learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGB) is 20–100 cases. Our aim was to investigate whether advanced laparoscopic skills could decrease the learning curve for LRYGB with regard to major morbidity. Methods The senior author performed all operations in this series. His training included a laparoscopic fellowship without bariatric surgery, six years in surgical practice focusing on upper abdominal laparoscopic surgery, two courses on bariatric surgery at national meetings, one week of observing a bariatric program, and two mentored LRGBY cases. A comprehensive obesity program was put in place before the program began. Data were collected prospectively and reviewed at the series’ end. Results are presented as mean ± standard deviation and standard statistical analysis was applied. Results Between December 2003 and February 2005, 107 LRYGB operations were performed. Mean operative time decreased significantly with experience (p < 0.0001) and was 154 ± 29, 132 ± 40, 127 ± 29, and 114 ± 30 min by quartile. Mean length of stay was 2.9 ± 1.6 days. Mean excess weight loss was 45.3% (n = 41) at six months. There were no conversions to an open procedure, no anastomotic leaks, no pulmonary embolisms, and no bowel obstructions. The five major complications (3 in the first 50 and 2 in the last 57 cases, p = NS) were two cases of biliopancreatic limb obstruction, two cases of significant gastrointestinal bleeding from anastomotic ulcer, and one case of gastric volvulus of the remnant stomach. Conclusions A bariatric fellowship and/or extended mentoring are not required to safely initiate a bariatric program for surgeons with advanced laparoscopic skills. Operative time decreases significantly with experience, but morbidity and mortality remain low even early in the learning curve. A comprehensive obesity program seems necessary for success. Presented at the Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, TX, 26–29 April 2006     

Bariatric surgery training in the United States.

BACKGROUND: To provide evidence of the status of bariatric surgical education in the accredited surgery training programs in the United States. METHODS: A questionnaire was sent by mail to the 251 accredited surgery residency training programs, including the 48 minimally invasive surgery fellowship programs, in the United States. RESULTS: There was a 100% response to the questionnaire. Of the 251 surgery residency training programs and 48 minimally invasive surgery fellowship programs, 185 (73.7%) and 43 (89.6%) performed bariatric surgery, respectively. The open Roux-en-Y gastric bypass was the dominant procedure (85.1%), followed by laparoscopic Roux-en-Y gastric bypass (60.9%), in the residency programs; the laparoscopic Roux-en-Y gastric bypass was the dominant procedure (70.1%) in the minimally invasive fellowship programs. CONCLUSIONS: Bariatric surgery has been mainstreamed into accredited training programs in the United States.     

Barrett’s Esophagus: A Late Complication of Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding has become a popular bariatric restrictive procedure in the USA. The increasing popularity of the laparoscopic adjustable gastric band procedure could, in part, be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass. Although its placement is related to a lower number of perioperative complications compared with laparoscopic gastric bypass, its morbidity may be substantial. Barrett’s esophagus or esophageal intestinal metaplasia is a known complication of chronic gastro-esophageal reflux disease that, in rare occasions, progresses to dysplasia and esophageal adenocarcinoma. Barrett’s esophagus, after laparoscopic adjustable gastric banding placement, is a rare but not unexpected complication after gastric band placement. The incidence of Barrett’s esophagus after adjustable gastric banding is not known. We present a case of Barrett’s esophagus as a result of laparoscopic adjustable gastric banding placement due to a chronically and highly restrictive gastric band in a former morbidly obese patient.     

Utilidad de la escala Obesity surgery mortality risk score en la predicción de complicaciones tras cirugía bariátrica por vía laparoscópica

Introduction

Morbimortality after bariatric surgery varies according to patient characteristics and associated comorbidities. The aim of this study was to evaluate the usefulness of the Obesity sugery mortality risk score scale (OS-MRS) to predict the risk of postoperative complications after bariatric surgery.

Methods

A retrospective study was performed of a prospective series of patients undergoing bariatric surgery in which the OS-MRS scale was applied preoperatively. Postoperative complications were classified as proposed by Dindo-Clavien. We analyzed the relationship between the categories of OS-MRS scale: A) low risk, B) intermediate risk, and C) high risk and the presence of complications.

Results

Between May 2008 and June 2012, 198 patients were included (85 [42.9%] after gastric bypass and 113 [57.1%] after sleeve gastrectomy). Using the OS-MRS scale, 124 patients were classified as class A (62.6%), 70 as class B (35.4%) and 4 as class C (2%). The overall morbidity rate was 12.6% (25 patients). A significant association between OS-MRS scale and rate of complications (7.3, 20 and 50%, respectively, P=.004) was demonstrated. The gastric bypass was associated with a higher complication rate than sleeve gastrectomy (P=.007). In multivariate analysis, OS-MRS scale and surgical technique were the only significant predictive factors.

Conclusions

The OS-MRS scale is a useful tool to predict the risk of complications and can be used as a guide when choosing the type of bariatric 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. This paper was presented at The Society for Surgery of the Alimentary Tract, 47th Annual Meeting, Los Angeles, CA, May 24, 2006.     

单中心1139例减重代谢手术经验总结

目的 总结单中心2009-2017年减重代谢手术经验，探讨学科构建方法。方法 回顾性分析2009年10月至2017年12月南京医科大学第一附属医院减重代谢外科完成的1139例减重代谢手术病例资料，分析病例数发展趋势、学习曲线以及并发症发生情况。结果 减重代谢专科成立后手术量呈逐年增长的趋势，年平均增长率40.1%，以腹腔镜胃袖状切除术（LSG）及其附加空肠旁路术（LSG+JJB）为主。术后并发症以出血及漏为主，其中死亡1例，再手术6例，出院30 d内再入院21例。腹腔镜胃旁路术（LRYGB）的学习曲线为23例，LSG学习曲线为25例。LSG、LRYGB及LSG+JJB的1年多余体重减少率分别为83.0%、72.4%及82.3%。术后1、3、5年的随访率分别为95.0%、67.0%及52.0%。结论 减重代谢专科设立是手术例数大幅度增长的关键因素。通过系统专科培训，可以缩短腹腔镜减重代谢手术的学习曲线，多学科综合治疗协作组（MDT）以及围手术期流程化管理是卓越中心建设的重要环节。     

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons

Background This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons. Methods From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants. Results Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10–150 cases) are needed for a claim of proficiency. Conclusion Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 2003 Scientific Session, 15 March 2003, Los Angeles, California     

Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers.

BACKGROUND: To compare the perioperative outcomes of bariatric surgery between adolescent (12-18 years) and adult (>18 years) patients for the treatment of morbid obesity using an administrative database. METHODS: Using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedural codes, we obtained data from the University HealthSystem Consortium for 55,501 morbidly obese patients (309 adolescents and 55,192 adults) who had undergone laparoscopic or open gastric bypass, laparoscopic gastric banding, or laparoscopic gastroplasty from 2002 to 2006. The outcome measures included demographics, length of hospital stay, intensive care unit stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality. RESULTS: The overall 30-day complication rate was significantly lower in the adolescent group (5.5% adolescents and 9.8% adults). The in-hospital and observed/expected mortality ratios were similar between groups. The greatest morbidity was associated with open gastric bypass procedures (7.6% for adolescents and 11.1% for adults) followed by laparoscopic gastric bypass (4.3% and 7.5%, respectively). Open gastric bypass in adults had the greatest observed/expected mortality ratio (1.0). In adolescents, the 30-day morbidity and mortality rate was 0% for restrictive procedures (laparoscopic adjustable gastric banding and gastroplasty). CONCLUSION: Bariatric surgery in adolescents represents a small subset of all bariatric operations performed at academic centers, although the number has increased threefold since 2002. Gastric bypass is the most commonly performed bariatric procedure in adolescents. The outcomes of bariatric surgery in adolescents appear to be as safe as those in adults, with lower 30-day morbidity.     

Laparoscopic Roux-en-Y Gastric Bypass: Differences in Outcome between Attendings and Assistants of Different Training Backgrounds

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a significant learning curve. We hypothesize that differences in surgeon and assistant training backgrounds may significantly impact outcomes during the learning curve. Methods: Retrospective analysis was performed on patients undergoing LRYGBP at an academic medical center between January 1998 and August 2003. Operations were performed by surgeons with different training backgrounds: without formal laparoscopic fellowship (S1, n=95); immediately following laparoscopic fellowship (S2, n=100); and with extensive laparoscopic experience post fellowship (S3, n=88). First assistants were attendings, fellows, or residents. The variables analyzed included demographics, operative times, estimated blood loss (EBL), rate of conversion, length of stay (LOS), ICU stay, re-operation/re-admission rate, and complications. Results were analyzed by ANOVA and Fisher's exact test. Results: There were significant differences among surgeons of different training backgrounds in EBL, LOS, rate of ICU admission, and intraoperative and late complications rates. Among assistants of different training levels, there were significant differences in operative time, EBL, intraoperative complication rates and re-admission rates. Conclusions: Differences in training background of the surgeons resulted in significant differences in outcome, including EBL, LOS, ICU admission and intraoperative and late complication rates. Lower assistant training levels significantly impacted efficiency through lengthened operative times and increased EBL, as well as increased intraoperative complication rates and re-admission rates. Our results suggested that participating in a laparoscopic fellowship and operating with a more experienced assistant may improve outcomes during the learning curve.     

Teaching robotic surgery: a stepwise approach

Background After an initial institutional experience with 50 robot-assisted laparoscopic Roux-en-Y gastric bypass procedures, a curriculum was developed for fellowship training in robotic surgery. Methods Thirty consecutive robotic gastric bypasses were performed using the Zeus robotic surgical system to fashion a two-layer gastrojejunostomy. For teaching purposes, performance of the anastomosis was divided into three discrete tasks. Robotic suturing tasks were assigned to the trainee in cumulative order in ten-case increments. Our patient population averaged 44 years of age and 47 kg/m² in BMI. Patients were predominantly female (87%). Results The robotic training experience of the fellow defines the increases in surgical responsibility over the series of cases. Statistical analysis revealed no significant differences in task times or total robotic operative time as participation of the trainee in performing the gastrojejunostomy increased. No adverse robotic events or surgical complications occurred throughout this series. The learning curve of the fellow compared favorably with the initial experience of the institution. Conclusion Robotic surgery training may be safely implemented in a minimally invasive surgery training program. A gradual introduction of robotic technique appears to maximize the learning experience and minimize the potential for adverse outcomes. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) April 13–16, 2005 in Fort Lauderdale, Florida, USA.     

An institutional experience with laparoscopic gastric bypass complications seen in the first year compared with open gastric bypass complications during the same period

BACKGROUND: Complication rates for laparoscopic bariatric surgery remain in evolution. METHODS: Single institution review of the initial year's experience with laparoscopic gastric bypass compared with open gastric bypass complications for the same period. RESULTS: There were 20 laparoscopic and 52 open gastric bypass procedures. Five laparoscopic patients had major complications. There were 4 anastomotic leaks. Nine open bypass patients had major complications, with 2 leaks. Leak rate was 20% for the laparoscopic group and 4% for the open group. All leaks in both groups led to substantial morbidity. There were two deaths, one in each group. The laparoscopic death was from postleak sepsis. CONCLUSIONS: Gastric bypass, whether done open or laparoscopically, has significant surgical risk. Complication profiles differed between the two groups. Anastomotic leaks were significantly more frequent in the laparoscopic group, probably related to the learning curve. There is a continued need for open surgery in many bariatric patients.     

Racial disparities in perioperative outcomes after bariatric surgery

BackgroundNonHispanic black patients bear a disproportionate burden of the obesity epidemic and its related medical co-morbidities. While bariatric surgery is the most effective treatment for morbid obesity, black patients access bariatric surgery at lower rates than nonHispanic white patients.ObjectivesTo examine racial differences before bariatric surgery and in short-term perioperative outcomes and complications, and the extent to which race is independently associated with perioperative morbidity and mortality.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database.MethodsData were extracted from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File. Multivariate analysis was used to identify differences in mortality, length of stay, readmission, and reintervention by race in patients undergoing laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy (SG).ResultsA total of 108,198 patients were included in the analysis. There were significant differences in perioperative disease burden. Black patients had a higher body mass index at the time they underwent surgery (laparoscopic Roux-en-Y gastric bypass: 48.0 versus 45.7 kg/m²; SG: 46.8 versus 44.9 kg/m²; P < .001). Black patients had significantly longer length of stay and higher rates of readmission in both the laparoscopic Roux-en-Y gastric bypass and SG groups. In the SG group, black patients had significantly higher 30-day mortality (.2% versus .1%, odds ratio = 3.613, 95% confidence interval 1.990–6.558, P < .001) and higher rates of reoperation or reintervention.ConclusionsWe found significant racial disparities in bariatric surgery outcomes, including higher mortality in black patients undergoing SG. The specific causes of these disparities remain unclear and must be the subject of future research.     

Outcomes of Laparoscopic Bariatric Surgery after Renal Transplant

Obesity has been associated with poor graft and patient survival after kidney transplantation, requiring functional increase of anti-rejection drugs. Weight loss surgery may be a good alternative in this clinical scenario. The aim of this report is to describe the outcomes of bariatric procedures performed in patients after kidney transplantation at our institution. A retrospective chart review of a prospectively collected database was conducted to analyze the outcomes of morbidly obese patients after kidney transplantation who underwent laparoscopic bariatric procedures between November 2004 and October 2007. Our series included five patients who underwent a bariatric procedure following kidney transplantation. All patients were females, with a mean age of 40.8 years (range 30–48) and mean body mass index (BMI) of 52.2 (range 48–69). Percent of excess weight loss (%EWL) at 2 years was over 50% for all patients; other comorbidities that might affect postoperative renal function were diabetes mellitus in 2/5 patients, hypertension in 5/5 patients, and chronic heart failure in 1/5 patients. Four patients had laparoscopic Roux-en-Y gastric bypass and one had laparoscopic sleeve gastrectomy. There were no postoperative complications in any patients, and no alteration to the dosages of the immunosuppressant drugs were recorded after bariatric surgery. Laparoscopic bariatric surgical techniques may be used safely and effectively to control obesity in renal transplant patients.     

Single-stage conversions from failed gastric band to sleeve gastrectomy versus Roux-en-Y gastric bypass: results from the United Kingdom National Bariatric Surgical Registry

Background

For patients in whom laparoscopic adjustable gastric band has failed, conversion to Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are both options for further surgical treatment. There are limited data comparing these 2 procedures. The National Bariatric Surgery Registry is a comprehensive United Kingdom–wide database of bariatric procedures, in which preoperative demographic characteristics and clinical outcomes are prospectively recorded.

The Learning Curve Measured by Operating Times for Laparoscopic and Open Gastric Bypass: Roles of Surgeon's Experience,Institutional Experience,Body Mass Index and Fellowship Training

Background: Surgeons must overcome a substantial learning curve before mastering laparoscopic Rouxen-Y gastric bypass (LRYGBP). This learning curve can be defined in terms of mortality, morbidity or length of surgery. The aim of this study was to compare the learning curves in terms of surgical time for the first 3 surgeons performing LRYGBP in our hospital with the length of surgery for open gastric bypass (CONTROLS). Methods: We compared 494 primary LRYGBPs performed by 3 surgeons (393 by 1st SURGEON, 57 by 2nd SURGEON and 44 by 3rd SURGEON) to 159 open vertical banded gastroplasty-Roux-en-Y gastric bypasses (CONTROLS). Data for LRYGBP patients were prospectively recorded while those for CONTROLS were retrospectively obtained. Factors that significantly affected the length of surgery were identified by univariate and multivariate linear regression analysis. Results: LRYGBP and CONTROL patients were similar in age, height, weight and BMI, although more CONTROLS were male. Median time for the 1st SURGEON performing LRYGBP dropped for each subsequent 100 operations: 1st 100 – 190 min, 2nd 100 – 135 min, 3rd 100 – 110 min and 4th 100 – 100 min. Median time for the 2nd SURGEON performing LRYGBP was 120 min, 3rd SURGEON 173 min and CONTROLS 64 min. Length of surgery significantly correlated with surgical experience in terms of number of operations and BMI of patient. Times for 2nd SURGEON, a fellowship trained laparoscopic surgeon, started significantly faster than 1st SURGEON's, but did not significantly improve with experience. 3rd SURGEON's initial times were similar to 1st SURGEON's, but his times improved more rapidly with experience. Times for CONTROLS were significantly faster than all laparoscopic groups and did not correlate with operation number or patient BMI. Conclusions: The length of surgery for LRYGBPs continued to shorten beyond 400 operations for the first surgeon performing LRYGBP in our hospital. Previous fellowship training in LRYGBP shortened surgical times during initial clinical experience as an attending for the second surgeon. The learning curve for a subsequent experienced laparoscopic surgeon was truncated because of the already established LRYGBP program.     

Laparoscopic bariatric surgery can be safe for treatment of morbid obesity in patients older than 60 years

BACKGROUND: Previous reports have questioned the safety of bariatric surgery in older patients. The aim of this study was to quantify the perioperative morbidity and mortality of older patients undergoing laparoscopic bariatric procedures at our institution. METHODS: A retrospective chart review of all laparoscopic bariatric procedures performed from February 1999 to September 2005 was performed to identify patients at Mount Sinai Medical Center who were older than 60 years at surgery. RESULTS: We identified 55 patients (36 women and 19 men). The mean age was 61.5 years (range 60-70), and the mean body mass index was 46.2 kg/m2 (range 38.1-61.0). Of the 55 patients, 33 (60%) had undergone laparoscopic Roux-en-Y gastric bypass, 9 (16%) laparoscopic gastric banding, 7 (13%) laparoscopic biliopancreatic diversion with duodenal switch, 3 (5.5%) laparoscopic revisional surgery, and 3 (5.5%) laparoscopic sleeve gastrectomy. The mean operative time was 2.3 hours (range 1.1-5.5). No patients required conversion to open surgery, and no perioperative mortality occurred within 30 days. The morbidity rate was 7.3% (n = 4). One patient developed an anastomotic bleed that was treated conservatively, and another patient developed an empyema that was successfully drained with a chest tube. That patient also developed a urinary tract infection, and another patient had a wound infection. The mean length of stay was 2.8 days (range 1-14). CONCLUSIONS: In a carefully selected patient population in a medical center with appropriate experience, laparoscopic bariatric surgery can be performed safely with low morbidity and mortality in the elderly population.     

Laparoscopic gastric bypass at a large academic medical center: lessons learned from the first 1000 cases

Bariatric surgery is an effective and durable treatment for morbid obesity in properly selected patients. Surgical outcomes and patient management methods should routinely be reviewed to improve patient care and maintain long-term effectiveness of the bariatric operation. Over a 5-year period, 1096 laparoscopic Roux-en-Y gastric bypass operations were performed at our institution. A comprehensive prospective database was maintained, which included data for comorbidities, operative techniques, perioperative management, complications, and follow up. Many practice patterns such as the omission of routine preoperative sleep apnea testing and biliary ultrasounds remained constant and were validated by the outcomes measured. Several changes, however, were implemented based on outcomes analyses, including antecolic placement of the roux limb, a pars flaccida approach to the creation of the gastric pouch, longer alimentary limbs in superobese patients, and a selective approach to postoperative upper gastrointestinal imaging. Postoperative weight regain and inability to maintain long-term follow up in a significant per cent of patients were two identified and ongoing problems. Maintenance of a bariatric patient database is essential with its routine review resulting in changes to practice patterns and operative techniques. An effective method for long-term patient follow up remains elusive and may contribute to postoperative weight regain in some patients.