Who Should Be Doing Laparoscopic Bariatric Surgery?

Background: The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. Methods: Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. Results: 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do >25 open before laparoscopic ones; and 3) clinical trials are needed (P<0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P<0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P<0.008). Conclusions:There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships.The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.     

Can Total Hip Arthroplasty for Hip Fracture Be Safely Performed by Trainees? A Retrospective Cohort Study

BackgroundNo research is available comparing trainee and consultant outcomes for total hip arthroplasty (THA) for hip fracture. The aim of our study is to determine whether trainee-performed and consultant-performed THA produced equivalent radiological outcomes and complication rates for this patient cohort.MethodsWe performed a retrospective cohort study at our institution, with inclusion of patients who underwent a primary THA for hip fracture between March 30, 2017 and February 07, 2019. Relevant perioperative and outcome data were collected through electronic records. Radiological outcomes were assessed by 2 independent reviewers. Follow-up was performed until August 07, 2019.ResultsEighty-seven patients were included in the study. The mean length of follow-up was 13 months (range, 6-29). Forty-three patients underwent consultant-led operations and 44 underwent trainee-performed (ST3-ST8) operations under consultant supervision. There were no significant differences between the 2 groups regarding complication risk (no recorded dislocation, infection requiring reoperation, revision or 30-day mortality in either group). There were also no significant differences between trainees and consultants regarding the radiological outcomes of mean acetabular component inclination (37.2° vs 36.7°, respectively, P = .74); offset difference (+7.1 mm vs +7.2 mm, respectively, P = .91); leg length difference (+6.4 mm vs +5.7 mm, respectively, P = .56); and barrack grade for femoral cement mantle.ConclusionThis study suggests that radiological and safety outcomes for trainees performing THA for hip fracture with appropriate supervision are equivalent to consultant surgeons. However, given the low event rate of complications, a larger study is required to determine whether there is any statistically significant difference.     

Can the Internal Iliac Artery Be Safely Covered during Endovascular Repair of Abdominal Aortic and Iliac Artery Aneurysms?

Aneurysmal involvement of the common iliac (CIA) or the internal iliac arteries (IIA) have been relative contraindications for safe endovascular aortic aneurysm (AAA) repair. Our goal was to review our experience in dealing with this problem by performing permanent coverage of one or both IIA during endoluminal repair of aneurysms of the aortoiliac region and to develop a safe, durable strategy. Of the 228 consecutive patients who had endoluminal repair of abdominal aortic (AAA) and iliac artery (IAA) aneurysms between 4/1999 and 4/2001 at our institution, 49 patients underwent coverage and/or coil embolization of one or both IIA during repair because of complex aortoiliac anatomy. These patients were evaluated prospectively for short-term adverse outcome. These results showed that CIA or IIA aneurysms can be managed safely during endoluminal repair of AAA. The IIA can be covered or embolized with minimum adverse consequences in patients who have inadequate CIA for deployment of the aortic or iliac endograft. Unilateral IIA occlusion is well tolerated. We advocate that whenever bilateral IIA occlusion is necessary during endovascular aneurysm repair, one of the IIAs should be revascularized if it is not aneurysmal.     

Understanding Hospital Readmissions After Pancreaticoduodenectomy: Can We Prevent Them?

Introduction

The morbidity and mortality of pancreaticoduodenectomy (PD) have significantly decreased over the past decades to the point that they are no longer the sole indicators of quality and safety. In recent times, hospital readmission is increasingly used as a quality metric for surgical performance and has direct implications on health-care costs. We sought to delineate the natural history and predictive factors of readmissions after PD.

Methods

The clinicopathologic and long-term follow-up data of 1,173 consecutive patients who underwent PD between August 2002 and August 2012 at the Massachusetts General Hospital were reviewed. The NSQIP database was linked with our clinical database to supplement perioperative data. Readmissions unrelated to the index admission were omitted.

Results

We identified 173 (15 %) patients who required readmission after PD within the study period. The readmission rate was higher in the second half of the decade when compared to the first half (18.6 vs 12.3 %, p?=?0.003), despite a stable 7-day median length of stay. Readmitted patients were analyzed against those without readmissions after PD. The demographics and tumor pathology of both groups did not differ significantly. In the multivariate logistic regression analysis, pancreatic fistula (18.5 vs 11.3 %, OR 1.86, p?=?0.004), multivisceral resection at time of PD (3.5 vs 0.6 %, OR 4.02, p?=?0.02), length of initial hospital stay >7 days (59.5 vs 42.5 %, OR 1.57, p?=?0.01), and ICU admissions (11.6 vs 3.4 %, OR 2.90, p?=?0.0005) were independently associated with readmissions. There were no postoperative biochemical variables that were predictive of readmissions. Fifty percent (n?=?87) of the readmissions occurred within 7 days from initial operative discharge. The reasons for immediate (≤7 days) and nonimmediate (>7 days) readmissions differed; ileus, delayed gastric emptying, and pneumonia were more common in early readmissions, whereas wound infection, failure to thrive, and intra-abdominal hemorrhage were associated with late readmissions. The incidences of readmissions due to pancreatic fistulas and intra-abdominal abscesses were equally distributed between both time frames. The frequency of readmission after PD is 15 % and has been on the uptrend over the last decade.

Conclusion

The complexity of initial resection and pancreatic fistula were independently associated with hospital readmissions after PD. Further efforts should be centered on preventing early readmissions, which constitute half of all readmissions.     

Can Postoperative Nausea and Vomiting Be Predicted?

Background: Retrospective [1] studies fail to identify predictors of postoperative nausea and vomiting (PONV). The authors prospectively studied 17,638 consecutive outpatients who had surgery to identify these predictors.

Methods: Data on medical conditions, anesthesia, surgery, and PONV were collected in the post-anesthesia care unit, in the ambulatory surgical unit, and in telephone interviews conducted 24 h after surgery. Multiple logistic regression with backward stepwise elimination was used to develop a predictive model. An independent set of patients was used to validate the model.

Results: Age (younger or older), sex (female or male), smoking status (nonsmokers or smokers), previous PONV, type of anesthesia (general or other), duration of anesthesia (longer or shorter), and type of surgery (plastic, orthopedic shoulder, or other) were independent predictors of PONV. A 10-yr increase in age decreased the likelihood of PONV by 13%. The risk for men was on third that for women. A 30-min increase in the duration of anesthesia increased the likelihood of PONV by 59%. General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia. Patients with plastic and orthopedic shoulder surgery had a sixfold increase in the risk for PONV. The model predicted PONV accurately and yielded an area under the receiver operating characteristic curve of 0.785 +/- 0.011 using an independent validation set.     

Can Total Knee Arthroplasty Be Safely Performed Among Nonagenarians? An Evaluation of Morbidity and Mortality Within a Total Joint Replacement Registry

As the nonagenarian patient population continues to grow, more patients aged 90 and over will become candidates for total knee arthroplasty (TKA). This study evaluated the patient characteristics and incidence of postoperative morbidity and mortality of 216 nonagenarian TKA patients among 81,835 primary TKA patients followed by a total joint replacement registry. Nonagenarians had a greater number of comorbidities preoperatively, experienced a higher rate of deep vein thrombosis and 30 day mortality, and had a longer hospital length of stay. However, nonagenarians did not have an increased risk of infection nor pulmonary embolism and postoperative mortality was within expected rates for individuals 90 years and older. Higher readmission rates, however, highlight the benefits of close follow up during a prolonged postoperative period.     

Can Bariatric Surgery be Performed Safely in Patients with Severe Treatment-Resistant Asthma?

Obesity-associated severe asthma is a distinct phenotype characterised by resistance to standard asthma therapies. Bariatric surgery appears to be a viable alternative for those who have failed trials of traditional weight loss methods. However, anaesthetic and surgical risks are potential barriers. We describe three patients with treatment-resistant obesity-associated severe asthma who underwent bariatric surgery without complications due to the multidisciplinary perioperative planning and care involved in these complex cases. All three patients showed improvements in asthma control and reduction in maintenance medication use post-surgery.