Bariatric surgery in a public hospital: a 10-year experience.

INTRODUCTION: Obesity is common and adversely impacts quality-of-life and healthcare cost. In Australia, less than 10% of bariatric surgeries are performed in the public sector. This study reports our 10-year experience from a high volume public bariatric service which delivers multi-disciplinary care for primary and revisional procedures with mid- to long-term follow-up. METHODS: A prospectively maintained database of all patients who underwent bariatric surgery from January 2010 to January 2020 at a tertiary metropolitan hospital was analysed. We analysed patient demographics, comorbidities, perioperative outcomes, 2- and 5-year weight loss as well as comorbidities reduction. RESULTS: A total of 995 patients underwent 1086 (674 primary and 412 revisional) bariatric procedures with mean age of 46.9 years, mean BMI of 49.6 ± 9.1 kg/m2 and 92% patients with ≥1 obesity-related co-morbidity. Length-of-stay was longer for revisional than primary surgery (5.6 vs. 3.5 days). Major complication rate was 4.2%. Overall, % Total body weight loss (%TBWL) for primary surgeries at 2 years was 26.2%, and for revision surgery was 17.4%. At 2 years follow-up, treatment was ceased or reduced in 65% of diabetics, 29% of hypertensive patients and 69% of sleep apnoea patients. CONCLUSION: This study confirms that bariatric surgery in Australia can be delivered effectively in resource constrained public health system with outcomes similar to private sector.

Development of an International Standardized Curriculum for Laparoscopic Sleeve Gastrectomy Teaching Utilizing Modified Delphi Methodology.

BACKGROUND: The performance of laparoscopic sleeve gastrectomy has increased markedly to become the single-most performed bariatric surgical procedure globally. To date, a means of standardized trainee teaching has not been developed. The aim of this study was to design a laparoscopic curriculum for trainees of bariatric surgery utilizing modified Delphi consensus methodology. METHODS: A panel of surgeons was assembled to devise an academic framework of technical, non-technical and cognitive skills utilized in the performance of laparoscopic sleeve gastrectomy. The panel invited 18 bariatric surgeons experienced in laparoscopic gastrectomy from 11 countries to rate the items for inclusion in the curriculum to a predefined level of agreement. RESULTS: A consensus of experts was achieved for 24 of the 30 proposed elements for inclusion within the first round of the curriculum Delphi panel. All components pertaining to anatomical knowledge, peri-operative considerations and non-technical items were accepted. A second round further examined six statements, of which three were accepted. Agreement of the panel was reached for 27 of the cognitive, technical and non-technical components after two rounds. Three statements found no consensus. CONCLUSIONS: Utilizing modified Delphi methodology, a curriculum outlining the most important components of teaching the procedure of laparoscopic sleeve gastrectomy, has been determined by a consensus of international experts in bariatric surgery. The curriculum is suggested as a standard in proficiency-based training of this procedure. It forms a generic template which facilitates individual jurisdictions to perform content validation, adapting the curriculum to local requirements in teaching the next generation of bariatric surgeons.

Video-Rated Performance Assessment of Simulated Laparoscopic Sleeve Gastrectomy: Validation of a Sleeve Gastrectomy Rating Scale.

PURPOSE: The global rise in obesity has been accompanied by widespread uptake of the procedure of laparoscopic sleeve gastrectomy. Despite this, the key components for performance assessment have not been standardized for this procedure. The aim of this study was to develop and demonstrate the validity of a Sleeve Objective Structured Assessment of Technical Skill (SOSATS) scale for learning the procedure of laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: The SOSATS evaluation tool was based upon critical steps of the LSG procedure. Both the SOSATS and the Global Rating Scale (GRS) component of the Objective Structured Assessment of Technical Skill (OSATS) tools were utilized in a prospective single-blinded observational study design of 26 video recordings of surgeons performing sleeve gastrectomies using a novel simulation. The surgeons were allocated into "novice" or "experienced" groups dependent on case-volume criteria. Surgical performance was assessed using both the GRS and SOSATS scales by blinded assessors of the video recordings. RESULTS: Face and content validity were demonstrated for key components of the simulated model. An overall positive correlation was established inferring concurrent validity between the accepted OSATS Global Rating Scale against the SOSATS procedural scale. Construct validity was established for a number of areas of the SOSATS scale. CONCLUSION: The SOSATS scale is shown to exhibit construct and concurrent validity in the simulated setting for the procedure of sleeve gastrectomy. Utilizing this scale to review surgical performance is potentially feasible and reliable but would require further research prior to use in high-stakes assessment processes such as credentialing.

Laparoscopic sleeve gastrectomy in a patient with situs inversus totalis and Kartagener syndrome: an unusual surgical conundrum.

Kartagener syndrome is a rare autosomal recessive condition. Approximately 25% of those with situs inversus totalis suffer the syndrome. With the rising overall number and indications for bariatric surgery, this condition will be increasingly recognised. We present a case of a 25-year-old woman with SIT and Kartagener syndrome who underwent a laparoscopic sleeve gastrectomy. As with all bariatric surgery, a multidisciplinary team approach was important in managing such a case. There were considerable cognitive challenges for the surgical team both preoperatively and during the procedure. The patient tolerated the operation well and was discharged 2 days after the surgery. At 12-months follow-up, the patient had achieved 125% excess weight loss. This case illustrates that an experienced surgeon can safely perform a laparoscopic sleeve gastrectomy on a patient with situs inversus totalis.

Giant perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass.

Perforation of a marginal ulcer (MU) is a complication of Roux-en-Y gastric bypass that can be life-threatening. We report a case of a perforated MU that presented 7 months after surgery with several interesting points for discussion. Firstly, the presentation of the ulcer was cryptic with unreliable investigations. Secondly, the ulcer presented again even after anastomotic revision surgery. Finally, the ulcer and the sepsis associated with perforation presented after months of poor nutritional intake with profound hypoalbuminaemia. Perforated MUs causing malnutrition pose clinicians with the difficult decision of which operation to offer; patch repair, revision of the anastomosis or reversal surgery. This case illustrates that primary reversal surgery for a perforated recurrent MU may be the most appropriate surgical management in this clinical situation.

A short course for surgical supervisors and trainers: effecting behavioural change.

BACKGROUND: The Supervisors and Trainers for the Surgical Education and Training (SAT SET) course was developed to assist surgical trainers in Australia and New Zealand with the transition to the new Surgical Education and Training framework. The aim of this study was to assess whether attendance at the course translated into behavioural change in surgical trainers and supervisors. METHODS: An online survey tool was distributed to registered participants in the SAT SET Course. Demographic data, attitudes towards the course and perceived behavioural change since attendance was measured. Data was collected using a 5-point Likert Scale with room for occasional free text comments. RESULTS: A 35% response rate was achieved for the study. Most thought the course was well designed, easy to follow and met its key aims. The majority felt more comfortable with the use of the new in-training assessment tools and had gained a more structured approach to analyse their trainees' performance. Most felt their roles as supervisors had been improved by attending the SAT SET course. Informal feedback to trainees had increased; however, structured feedback rates remained low. Fears that the new system would increase the workload on supervisors did not seem to have materialized. Of the respondents, 43% considered that objective assessment of trainees had improved without fear of legal implications. CONCLUSIONS: The SAT SET course appears to have been well received and has helped better inform participants of their roles and has resulted in an appreciable positive behavioural change in their practice as surgical supervisors.

Salutary swan song for the Starr Edwards valve.

The Starr-Edwards valve was the first manufactured valve to be used successfully as a cardiac valve replacement in 1960. Although superseded by newer valves over the decades it has achieved an excellent track record. It has unique features, namely a protective metal casing around the ball poppet and a large and thick sewing ring. We describe the last implant of this valve in Australia; it has now been withdrawn by the manufacturer. In this particular case, the unique features of this valve made the required surgery quite simple and avoided the need for complex mitral valve surgery in a very high-risk patient.

Complex coronary sinus fistula in a 58-year-old female.

Coronary artery aneurysms and arterio-venous fistulae are uncommon malformations. We report the case of a 58-year-old woman with a large aneurysmal fistula arising from the left coronary tree and involving the entire coronary sinus venous system, resulting in significant left-to-right shunt. We discuss the management of aneurysmal fistulae of the coronary arteries, and the merits of prophylaxis for thrombotic complications of large aneurysms. We recommend consideration of warfarinisation in addition to aspirin of such patients post-operatively.

Thrombus straddling an atrial septal defect: surgical prevention of massive pulmonary and systemic embolization.

A large thrombus entrapped in an atrial septal defect is a rare condition that can lead to life-threatening systemic and pulmonary embolization. The use of thrombolysis may prove dangerous to the patient. Herein, we describe the emergency surgical management that contributed to a successful outcome in a 67-year-old man who was found to have a 23-cm-long thrombus across an atrial septal defect.

Eliminating the limitations of manual crimping in stapes surgery: mid-term results of 90 patients in the Nitinol stapes piston multicenter trial.

OBJECTIVE: To present our mid-term results of our multicenter study using the Nitinol self-crimping stapes piston, focusing on the interindividual variations of postoperative air-bone gap closures (ABGC), postoperative hearing results, and postoperative recurrences of conductive hearing loss and to compare these findings with our pilot group of patients. STUDY DESIGN: Prospective, multicenter cohort study involving three academic tertiary care referral centers from Australia, Switzerland, and the United States. METHODS: Ninety patients with otosclerosis undergoing laser-stapedotomy with the Nitinol stapes piston were matched to reference patients from our titanium piston database. The effects of the self-crimping Nitinol piston on the postoperative ABGC, the postoperative interindividual air-bone gap (ABG) variations, and the postoperative hearing results were investigated 3, 6, 12, 18, and 24 months postoperatively. These data were statistically compared with the results of the control patients in our titanium stapes piston database and the results of our previously published pilot study. RESULTS: The mean postoperative ABG and the interindividual variations of the postoperative ABG continue to be significantly smaller in the Nitinol group; the extent of ABGC now is significantly larger in the Nitinol piston group. The postoperative mid-term stability of ABGC was similar in both groups. No adverse reactions occurred during follow-up. CONCLUSION: Our mid-term results continue to show that the self-crimping shape memory alloy Nitinol stapes piston overcomes the limitations of manual malcrimping in stapedotomy, thus simplifying and optimizing the surgical procedure. This so far has allowed reliable, safe, and consistent ABGC in patients with otosclerosis.

Prevocational medical training and the Australian Curriculum Framework for Junior Doctors: a junior doctor perspective.

The current system of prevocational training does not meet the needs of junior doctors because of a high administrative workload, insufficient funding for education, and a lack of centralised guidance for trainees, teachers and hospitals. The Australian Curriculum Framework for Junior Doctors is designed to identify the training objectives for the prevocational years. The Framework has the potential to improve the quality of training of junior doctors, but this depends on how well it is implemented and resourced. It is imperative that any group responsible for implementing or assessing the Framework have a representative junior doctor, among others, on its decision-making committee. Stringent accreditation of training institutions is vital to the effective implementation of the Framework. The Framework should be used to promote teaching and learning, not as a barrier to vocational training or as a check-list to complete.

Second branchial cleft sinus presenting after adenotonsillectomy.

Branchial cleft sinuses are one of the more common congenital defects arising in the head and neck region. Second branchial cleft anomalies are the commonest of the true branchial cleft defects and the diagnosis is usually straightforward. We report the case of an atypical presentation of branchial cleft sinus that manifested after adenotonsillectomy. To our knowledge this is the first reported case of a second branchial cleft sinus presenting only after adenotonsillectomy. The sinus was excised with no recurrence of symptoms at 12 months of follow-up.