Safety and feasibility of destination care for bariatric surgery: a single institution retrospective study.

INTRODUCTION: Increasing emphasis on value-based healthcare has prompted both employers and healthcare organizations to develop innovative strategies to supply high quality care to patients. One such strategy is through the bundled care payment model (BCPM). Through this model, our institution partnered with employers from across the country to provide quality care for their members. Patients traveling greater than 2 h driving time from the bariatric center were considered "destination" patients. To properly care for our destination patients, our institution created a "destination bariatric program." We sought to investigate comparative outcomes for the first 100 patients who completed the program. We hypothesized that there would be no difference in patient outcomes or complications between destination and local patient groups undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). METHODS AND PROCEDURES: A retrospective cohort analysis of patients undergoing bariatric surgery at a MBSAQIP-accredited bariatric surgery center between May 2019 and October 2021 was conducted. Patients were divided into destination or local patient groups based on participation in the established destination surgery program. Patient demographics, perioperative clinical outcomes, and complications were compared and statistically analyzed using two-sample t-tests, Chi-square tests, Fisher's exact tests, and univariate logistic regressions. RESULTS: This study identified 296 patients, which consisted of destination (n = 110) and local (n = 186) patient cohorts. Patients in the destination group had higher rates of diabetes mellitus (29.1% vs 24.2%, p = 0.029), but otherwise cohorts had similar basic demographics and comorbidities. Outcomes revealed no statistically significant associations between patient cohort (destination versus local) and ED admission (p = 0.305), hospital readmission (p = 0.893), surgical reintervention (p = 0.974), endoscopic-reintervention (p = 0.714), and patient complications in the postoperative period (30 days). CONCLUSION: Participation in destination care programs for bariatric surgery was found to be both safe and feasible. These destination programs represent an opportunity to provide a broader patient population access to complex surgical care.

SAGES white paper on the current state of community practice surgeons: re-discovering the value of our community practice surgeons.

BACKGROUND: The Community Practice (CP) surgeon is the first point of access to surgical care globally and performs the majority of procedures in the USA. CP surgeons include those of various practice models, locations and communities, education and training, and much more. It is a diverse group that drives quality, access to care, research, and innovation. The SAGES CP Committee was formed to better define the role and highlight the contribution of the CP surgeon, as well as advocate for the position of CP surgeons in our society. METHODS: In 2018, a survey was distributed to the SAGES membership asking members to self-identify as either a Community Surgeon or Academic Surgeon. RESULTS: The majority (71%) of SAGES members surveyed self-identified as "Community Surgeons." This was in stark contrast to the distribution of Community versus Academic Surgeons in SAGES leadership (25% versus 75%, respectively). CONCLUSION: By better defining the characteristics and role of the CP, SAGES will be better informed on how to effectively engage with this large group within the society and increase its representation within the leadership. The CP Committee met on a biannual basis over a period of two years focusing on assessing their role in the SAGES organization. The committee members created the following initial goals: (1) define in a broad sense the characteristics of a CP Surgeon, (2) discuss and characterize the value of the CP surgeons, (3) highlight past and future areas of contributions of the group, and (4) delineate ways to engage and represent this subgroup. This manuscript is a culmination of the work of this committee while also serving as a way to support the initiatives and direction of SAGES leadership.

Community hospital decreases narcotic usage in postoperative bariatric patients.

BACKGROUND: Opioids have long been used as an effective form of analgesia for pain in the postoperative setting; however, their addictive potential and associated complications have become a detriment. There has been an increasing movement to decrease opioid prescribing. OBJECTIVE: The aim of this study was to look at common bariatric surgery procedures at a single institution and compare opioid usage before and after the implementation of a multimodal pain regimen. SETTING: Community program, hospital-employed, and private practice, United States. METHODS: Six hundred twelve laparoscopic gastric bypass and laparoscopic sleeve gastrectomy patients were included in this single-institution retrospective cohort study. Data were obtained from chart review. Comparison was made between patients from 2016 and patients from a 3-month period in 2017 when the new pain management protocol had been instituted. RESULTS: The postoperative opioid usage of 516 patients from 2016 was compared with that of 96 patients from a 3-month period in 2017 after initiating the new pain management protocol. The mean intravenous hydromorphone usage of the control group, 16.0 ± 14.6 morphine milligram equivalent (or 4.0 mg ± .2), over the postoperative inpatient stay decreased to 7.3 ± 6.7 morphine milligram equivalent (or 1.8 mg ± .2) in the study group. This represents a 55% decrease. The study group did show less 30-day postoperative complications compared with the control, 1.04% and 2.13%, respectively, although this was not statistically significant. CONCLUSION: A multimodal pain regimen is an effective way to cut opioid usage with no statistical difference in overall 30-day complications.

Effect of minimally invasive surgery fellowship on residents' operative experience.

INTRODUCTION: There is an increased need for surgical trainees to acquire advanced laparoscopic skills as laparoscopy becomes the standard of care in many areas of general surgery. Since the introduction of minimally invasive surgery (MIS) fellowships, there has been a continuing debate as to whether these fellowships adversely affect general surgery resident exposure to laparoscopic cases. The aim of our study was to examine whether the introduction of an MIS fellowship negatively impacts general surgery residents' experience at a single academic center. METHODS: We describe the changes following establishment of MIS fellowship at an academic center. Resident case log system from the Accreditation Council for Graduate Medical Education was queried to obtain all PGY 1-5 resident operative case logs. Two-year time period preceding and following the institution of an MIS fellowship at our institution in 2012 was compared. P values less than 0.05 were considered statistically significant. RESULTS: Following initiation of the MIS fellowship, an MIS service was established. The service comprised of a fellow, midlevel resident, and intern. Operative experience was examined. From 2010-2012 to 2012-2014, residents logged a total of 272 and 585 complex laparoscopic cases, respectively. There were 43 residents from 2010 to 2013 and 44 residents from 2013 to 2014. When the two time periods were compared, a trend of increased numbers for all procedures was noted, except laparoscopic GYN/genito-urinary procedures. Average percent increase in complex general surgery procedures was 249 ± 179.8 %. Following establishment of a MIS fellowship, reported cases by residents were higher or similar to those reported nationally for laparoscopic procedures. CONCLUSION: Institution of an MIS fellowship had a favorable effect on general surgery resident operative education at a single academic training center. Residents may benefit from the presence of a fellowship at an academic center because they are able to participate in an increased number of complex laparoscopic cases.

Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy.

INTRODUCTION: Common bile duct (CBD) injury is a serious and dreaded complication of cholecystectomy. A paucity of data assessing long-term outcomes exists. This study aimed to determine long-term mortality and liver transplantation rates following CBD injury requiring operative intervention. METHODS: Patients were identified via the New York State (NYS) Planning and Research Cooperative System longitudinal administrative database which captures patient-level data from every inpatient and outpatient hospital discharge in NYS. In total, 125 patients with CBD injuries were identified following 156,958 laparoscopic cholecystectomies for cholelithiasis performed in NYS from 2005 to 2010. Patients were then tracked by unique identifier to obtain rate of liver transplantation. Follow-up ranged from 4 to 9 years from surgery. RESULTS: There were 125 patients with CBD injuries detected. No mortalities occurred within 30 days. All-cause mortality was 20.8 % (n = 26) with mean time to death 1.64 ± 1.08 years. One patient who underwent hepaticoenterostomy required a liver transplant 4.3 years after surgery. Significant factors predictive of all-cause mortality included: age >61, Medicare insurance, male gender, White race, diabetes, hypertension and pulmonary complications following surgery. Overall 30-day morbidity, timing to and type of operative intervention did not influence mortality. CONCLUSION: Considerable long-term mortality, 20.8 %, is associated with common bile duct injury requiring operative intervention. This was an increase of 8.8 % above the cohort's expected age-adjusted rate of death. The mortality rate is appreciably higher than quoted previously. No difference was demonstrated by type of repair required. Liver transplant rate was 0.8 %. These data have significant implications for patient and family counseling both prior to cholecystectomy and following CBD injury.

Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era.

BACKGROUND: Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve. METHODS: The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery. RESULTS: From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Of the total patients, 149 patients underwent a biliary duct procedure within a year. Twenty-four of them were diagnosed with gallbladder cancer and excluded, leaving 125 for further analysis. The biliary injuries were identified at a rate of 0.080 %. Thirty-one of those patients (24.8 %) underwent hepatectomy, 40 patients (32.0 %) underwent hepaticoenterostomy, and 54 patients (43.2 %) underwent primary repair of the bile duct. Thirty-two (26 %) patients were repaired on the same day of their initial procedure. Of the remaining 93 patients, 38 (30 %) were repaired within 10 days, seven (6 %) repaired between 11 and 20 days, and 48 (38 %) patients over 21 days from injury. CONCLUSION: In NYS, the rate of bile duct injury has now decreased to 0.08 % and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience, improved instrumentation, and movement beyond the "learning curve."

Lap band outcomes from 19,221 patients across centers and over a decade within the state of New York.

INTRODUCTION: We sought to determine the rate of revision and explant of the laparoscopic adjustable gastric banding (LAGB) over a ten-year period in the state of New York. METHODS: Following IRB approval, the SPARCS administrative database was used to identify LAGB placement from 2004 to 2010. We tracked patients who underwent band placement with subsequent removal/revision, followed by conversion to either Roux-en-Y gastric bypass (RYBG) or sleeve gastrectomy (SG) between 2004 and 2013. McNemar test and Chi-square test were used to compare complications between primary procedure and subsequent revision and to compare complication rates and mortality rates, respectively. Log-rank test was used to assess patient characteristics and comorbidities. p < 0.05 was considered significant. RESULTS: During a 7-year period, there were 19,221 records of LAGB placements and 6567 records of revisions or removal. We were able to follow up 3158 (16.43 %) who subsequently underwent a band removal or revision over the course of this period. An additional 3606 patients had no records in the state of New York following the procedure, thus making the rate of revision 20.22 %. Initial revision procedures were coded as band removal in 32.77 % (n = 1035), band revision in 30.53 % (n = 964), band removal and replacement in 19.09 % (n = 603), removal and conversion to SG in 5.64 % (n = 178), or removal and conversion to RYGB in 11.97 % (n = 378). From the 3158 patients, 2515 (79.64 %) required only one revision. Six hundred and forty-three patients underwent two or more revisions. Thirty-one out of 3158 (0.0098 %) patients had complications at their initial operation, but 919 (29.1 %) had complications during revision (p < 0.0001). CONCLUSIONS: Over a 7-year period, at least 20.22 % of LAGB required removal or revision. Based on all case numbers, total revision rate may be as high as 34.2 %. Although the band is believed to be a reversible procedure, revisional procedures are significantly more morbid than the initial procedure.

Robotic approaches may offer benefit in colorectal procedures, more controversial in other areas: a review of 168,248 cases.

INTRODUCTION: While the penetrance of robotic surgery into field of urology and gynecology has been significant, general surgeons have been slower adopters. We sought to compare laparoscopy and RAS among five different general surgical procedures with various penetrance of MIS. METHODS: Following IRB approval, the New York Statewide Planning and Research Cooperative System administrative data were used to identify five common laparoscopic general surgery procedures: cholecystectomy, colectomy, esophageal fundoplication (EF), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) between 2008 and 2012. ICD-9 codes were used to select laparoscopic versus robotic procedures. Procedures were compared based on any complication and hospital length of stay (HLOS). Following descriptive analysis, propensity score analysis was used to estimate the population average differences between patients who underwent robotic-assisted and laparoscopic procedures. RESULTS: There were 1458 patients who had undergone robotic-assisted surgery and 166,790 patients who had undergone laparoscopic surgery among the five procedures between 2008 and 2012. Of the 1458 robotic cases, 186 were cholecystectomy, 307 were RYGB, 118 were SG, 288 were EF, and 559 were colectomy. Initial univariate analysis showed a significantly higher rate of overall complications and HLOS in the laparoscopic group compared to the robotic-assisted group. Laparoscopic colectomy had a significantly higher rate of complications and longer length of stay compared to robotic approaches. No difference in complications or HLOS was seen in the cholecystectomy group. Following propensity score analysis, patients who had undergone robotic-assisted colectomy had significantly lower rate of complications compared to those who underwent conventional laparoscopic procedure (p value = 0.0022). In addition, patients who underwent robotic-assisted SG had on average 1.22 days longer HLOS (p value = 0.0037). CONCLUSION: Robotic approaches may facilitate safer adoption of minimally invasive approaches in areas where penetrance of conventional laparoscopy is low, such as in colorectal surgery.

Self-assessed learning style correlates to use of supplemental learning materials in an online course management system.

BACKGROUND: The benefit of online learning materials in medical education is not well defined. AIM: The study correlated certain self-identified learning styles with the use of self-selected online learning materials. METHODS: First-year osteopathic medical students were given access to review and/or summary materials via an online course management system (CMS) while enrolled in a pre-clinical course. At the end of the course, students completed a self-assessment of learning style based on the Index of Learning Styles and a brief survey regarding their usage and perceived advantage of the online learning materials. RESULTS: Students who accessed the online materials earned equivalent grades to those who did not. However, the study found that students who described their learning styles as active, intuitive, global, and/or visual were more likely to use online educational resources than those who identified their learning style as reflective, sensing, sequential, and/or verbal. CONCLUSIONS: Identification of a student's learning style can help medical educators direct students to learning resources that best suit their individual needs.