Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy.

BACKGROUND: Despite excellent reported outcomes after laparoscopic sleeve gastrectomy (LSG), a percentage of patients go on to have a secondary bariatric surgery to manage side-effects or address weight regain after LSG. Reported weight loss outcomes for patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) after previous LSG are variable. We sought to determine the weight-loss outcomes of patients undergoing LRYGB after LSG in the largest bariatric surgical network in Canada and to determine whether outcomes differ according to indications for conversion. METHODS: The Bariatric Registry is a multi-center database with prospectively collected standardized data on patients undergoing bariatric surgery at ten Bariatric Centers of Excellence within the Ontario Bariatric Network in Ontario, Canada. A retrospective analysis was performed of patients who underwent LRYGB after previous LSG between 2012 and 2019. Weight loss outcomes were compared between patients who underwent LRYGB for insufficient weight loss/weight regain and those who underwent conversion to LRYGB for other reasons. RESULTS: Excluding patients with multiple revisions and those without follow-up data, 48 patients were included in the analysis: 33 patients (69%) underwent conversion to LRGYB for insufficient weight loss/weight regain (Group 1) and 15 patients (31%) underwent conversion for other reasons (Group 2). Mean body mass index (BMI) measured pre-LSG, pre-LRYGB, and at mid-term follow-up after LRYGB was 61, 48, and 43 kg/m2 in Group 1 and 51, 39, and 34 kg/m2 in Group 2, respectively. ΔBMI and %total weight loss (TWL) at mid-term follow-up were not significantly different between the groups. CONCLUSIONS: Conversion to LRYGB after previous LSG resulted in an additional loss of 4 kg/m2 in BMI points at mid-term follow-up. Patients lost a similar number of BMI points and cumulative %TWL was similar regardless of reason for conversion. This can help inform surgical decision-making in the setting of weight regain after LSG.

Development of consensus-derived quality indicators for laparoscopic sleeve gastrectomy operative reports.

BACKGROUND: Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for the laparoscopic sleeve gastrectomy and to generate parameters by which these reports can be evaluated and improved. METHODS: A Delphi protocol was used to determine quality indicators for LSG. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Transferrable consensus items for LSG from previously developed Roux-en-Y gastric bypass operative indictors were put forward for consideration. Participants also initially submitted potential QIs. These were grouped by theme. Items were rated on 5-point Likert scales in subsequent rounds. Scores of 70% or higher were used for inclusion and 30% or less denoted exclusion. Elements scoring 30% to 70% agreement were recirculated by runoff in subsequent rounds to generate the final list of quality indicators. RESULTS: Seven bariatric surgeons, representing all regions preforming LSG in Canada, were invited to participate in the Delphi group. Multidisciplinary invitees included one academic minimally invasive/acute care surgeon, one tertiary abdominal radiologist, and one academic gastroenterologist with bariatric expertise. Two rounds were required to achieve consensus. Both rounds achieved a 100% response (10/10). In round 1, forty items reached consensus. In Round 2, an additional 28 items reached consensus, with three items excluded, bringing the total number of quality indicators to 65. CONCLUSION: This study establishes consensus-derived multidisciplinary quality indicators for LSG operative reports. Application of these findings aims to advance the quality and completeness of operative reporting in LSG in order to improve communication of important surgical details and quality measures to the multidisciplinary team involved in bariatric surgery care.

Outcomes from Explantation of Laparoscopic Adjustable Gastric Band: Experience from a Canadian Bariatric Center of Excellence.

PURPOSE: Laparoscopic adjustable gastric banding (LAGB) has declined in popularity due to poor weight loss and high revision rates. The study aim was to evaluate complication rates following LAGB removals, including conversions to other bariatric procedures. MATERIALS AND METHODS: This was a retrospective cohort study of patients who underwent LAGB removal, identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from the Toronto Western Hospital site. Patients were filtered using principal procedure and concurrent procedural terminology (CPT) codes. Patients converted to other bariatric procedures were also included. Outcomes were evaluated for 30-day morbidity, mortality, readmissions, and costs. RESULTS: From 2012 to 2018, 93 patients met inclusion. 96.77% had elective surgery, and 3.23% were emergent. Thirty-day postoperative complication rate was 11.83%, with 4.30% readmissions and no deaths. Surgical site infections accounted for 81.82% of complications (54.55% superficial, 27.27% deep). Thirty-day complication rate for LAGB removal alone was 17.50% and 33.33% following emergent explantation. 56.99% LAGBs were converted to other bariatric procedures: 48.39% laparoscopic Roux-en-Y gastric bypass (LRYGB) and 8.6% sleeve gastrectomy (LSG). Conversion to LSG had a significantly higher 30-day complication rate (all Clavien-Dindo class I-II) compared to conversion to LRYGB (37.50% versus 2.22%, p < 0.009). Direct costs of LAGB explantation to the healthcare system were $665,443, amounting to $7,155 per patient. CONCLUSION: Thirty-day complication rates for LAGB explantation and conversion to other bariatric procedures are significant and may be higher than previously reported for LAGB removal alone. Conversion to LSG may have the highest complication rate, amounting to significant costs.

Fellow and Attending Surgeon Operative Notes are Deficient in Reporting Established Quality Indicators for Roux-en-Y Gastric Bypass: A Preliminary Retrospective Analysis of Operative Dictation.

Introduction Surgeons must dictate the important components of any invasive procedure in a comprehensive, yet concise, operative report. This documentation is vital for communicating operative events and has implications for providing additional healthcare and planning future operations. The quality of surgical care may be impaired in the absence of such communication. Evidence suggests that the quality of reports dictated by trainees and surgeons is poor despite its importance. This investigation analyzed and compared the quality of fellow and staff surgeon Roux-en-Y Gastric Bypass (RYGB) narrative dictations against validated and reliable quality indicators (QIs) for this procedure. Methods A total of 40 bariatric fellow reports and 40 attending RYGB narrative reports were retrospectively analyzed. Results Fellows had a mean completion of 66.4% +/- 3.1% as compared to 61.5% +/- 7.6% for attendings (p<0.0001). Fellows statistically outperformed attendings on all subsections except patient, closure, and postoperative details. Attendings statistically outperformed fellows on closure details only (63.8 +/- 7.5 vs 50.5 +/- 12.0, p=0.002). Conclusions Bariatric surgery trainees outperform attending surgeons in RYGB operative dictation. The clinical significance of this difference is unknown. However, both groups are deficient in reporting at least one-third of items deemed essential to RYGB operative reporting. This indicates a need for further education in RYGB dictation for practicing surgeons and trainees. It also lends interest in exploring alternative forms of operative communication such as synoptic operative reporting in bariatric surgery.

Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature

Background: Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model. Methods: We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate. Results: The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied. Conclusion: Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.

Contexte: Des modèles dédiés de services de chirurgie générale d'urgence (CGU) ont été développés pour améliorer l'efficience des soins et les résultats chez les patients. On ne s'entend toutefois pas sur l'ampleur des bénéfices conférés par le modèle CGU. Nous avons procédé à une revue systématique de la littérature afin de vérifier si le modèle CGU est associé à une plus grande efficience et à de meilleurs résultats comparativement au modèle classique. Méthodes: Nous avons interrogé les bases de données MEDLINE, Embase, Scopus et Web of Science (collection centrale) depuis la plus ancienne couverture du sujet et jusqu'à mars 2017. Les paramètres principaux pour l'efficience des soins étaient le temps de réponse, le délai avant l'intervention et la durée totale du séjour hospitalier. Le paramètre principal pour l'évaluation des résultats chez les patients était le taux de complications total. Résultats: Le modèle de service CGU améliore généralement l'efficience des soins et les résultats chez les patients, mais dans la littérature, les paramètres mesurés varient. Conclusion: Le développement de paramètres standardisés et de bases de données globales sur la CGU appuierait le contrôle de la qualité et l'amélioration du rendement des systèmes CGU.

Advancement in the quality of operative documentation: A systematic review and meta-analysis of synoptic versus narrative operative reporting.

BACKGROUND: The operative report is vital for patients and central to surgical quality assessment. Narrative operative reports are often poor quality. Synoptic reporting can improve documentation. The objective was to identify and appraise studies comparing synoptic and narrative operative reporting. DATA SOURCES: A systematic review of the literature was performed. The primary outcome was completion of critical elements for an operative report. Additional secondary outcomes were measured. Meta-analysis was performed where possible. Quality analysis was performed using Newcastle-Ottawa Scale (NOS). RESULTS: 1471 citations were identified; 16 studies included. Mean NOS was 7.09 out of 9 (+/-- SD 1.73). Meta-analysis demonstrated that synoptic reporting was significantly more complete (SMD 1.70, 95% CI 1.13 to 2.26; I2 98%). Completion time was shorter with synoptic reporting (mean difference -0.86, 95% CI -1.17 to -0.55). Secondary outcomes favoured synoptic reporting. CONCLUSIONS: Synoptic reporting platforms outperform narrative reporting and should be incorporated into surgical practice.

Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass.

OBJECTIVE: Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB). METHODS: A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland-Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared. RESULTS: The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t = 57.9, p < 0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p < 0.001) except for small bowel division details (p = 0.530). Accuracy was significantly higher for SR than NR (94.2% ± SD 4.31% vs. 53.6% ± SD 9.82%, respectively, p < 0.001). Rater agreement was excellent for both SR (0.11, 95% LOA -0.53 to 0.75) and NR (-0.26, 95% LOA -4.85 to 4.33) (p = 0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55 min ± SD 1:26 min and 4:50 min ± SD 0:50 min, respectively, p = 0.007). CONCLUSION: The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

Electronic synoptic reporting: assessing the completeness of synoptic and narrative reports for Roux-en-Y gastric bypass.

BACKGROUND: Operative reporting is the foundation of surgical communication. The quality indicators (QIs) contained in these reports can be used to document the performance of processes that affect patient care and may afford quality assurance with improvement in healthcare. OBJECTIVES: We assessed the degree to which the electronic synoptic report (SR) documents the operative QIs compared with narrative reports (NR) for Roux-en-Y gastric bypass (RYGB). The time to report availability on patient chart was also identified as a secondary measure. SETTING: Academic center, public hospital, Canada. METHODS: A total of 40 prospectively collected RYGB synoptic reports and 40 case-matched historical NRs were compared against checklist QIs that were established by a national Delphi process. These checklist QIs are validated and have high interrater agreement at our institution. Time from dictation to report availability on patient chart was measured. RESULTS: SR had a mean completion of 99.7% (±standard deviation [SD] 1.3%) compared with 64.0% (±SD 6.3%) for NR (t = 36.0, P<.0001). All subsections of SR were>99% complete and significantly higher than NR (P<.001). The mean time from NR dictation to report availability was 4.14 days (SD±3.17, range 0-10 d). All SRs were in the operative area after the procedure and were available immediately. CONCLUSION: The RYGB synoptic report is superior to the narrative report for inclusion of accepted quality indicators and time to availability. Important elements, including process of care, demographic characteristics, and anatomic-related data, were often missing from the NR. SR is a promising method for improving documentation for RYGB.

Bariatric operative reporting: Quality assessment and perceptions among bariatric surgeons.

BACKGROUND: The quality of narrative operative notes is poor. No investigation has previously addressed operative reporting specifically in bariatric surgery. OBJECTIVES: To evaluate surgeons' perceptions of the quality of operative reporting in bariatric surgery and compare this to an audit of Roux-en-Y gastric bypass (RYGB) narrative reports using validated quality indicators. SETTING: University hospital, Canada. METHODS: A Web-based survey was distributed to bariatric surgeons across Canada. Perceptions regarding the quality of reporting were gathered using a Likert scale (modified Structured Assessment Format for Evaluating Operative Reports) and free text fields. Forty RYGB narrative reports were analyzed against established quality indicators and compared to respondent's perceptions based on themes. RESULTS: Twenty-four of 34 bariatric surgeons (71%) completed the survey. The most commonly performed procedures were RYGB and sleeve gastrectomy (96% and 100%, respectively). Currently, 70.8% perform a traditional narrative report. The average Structured Assessment Format for Evaluating Operative Reports score for narrative dictations by bariatric surgeons was neutral (27.9/40). The lowest scoring items were the "description of indications" (2.9/5) and "succinctness" (3.3/5). Opinions reflected a need for an immediately generated, standardized, template-based report to improve the quality and accessibility of operative documentation. The quality audit reinforced respondents' perceptions. Reports included only 62.0%±6.6% of quality indicators, with the lowest scoring areas being "patient details," "preoperative events," and "postoperative details" (41.1%, 32.4%, and 31.7%, respectively). CONCLUSION: This survey revealed a perception of mediocre quality of narrative dictations. This was reinforced by an audit of RYGB operative reports. Future investigations should focus on improving this form of operative communication.

Development of consensus-derived quality indicators for laparoscopic Roux-en-Y gastric bypass surgery.

BACKGROUND: Synoptic operative reporting is a solution to the poor quality of narrative reports. OBJECTIVE: To develop operative report quality indicators (QI) for laparoscopic Roux-en-Y gastric bypass (LRYGB) to generate validated parameters by which these reports can be evaluated and improved. SETTING: University hospital in Canada. METHODS: A Delphi protocol was used to determine QIs for LRYGB reporting. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Participants initially submitted potential QIs. These were grouped by theme. Items were rated on 9-point Likert scales in subsequent rounds. Scores of 70% or greater were used for inclusion consensus, and 30% or less denoted exclusion. Elements scoring 30% to 70% were recirculated by runoff in subsequent rounds to generate the final list of QIs. RESULTS: Four community and 4 academic bariatric surgeons were invited, representing all provinces performing LRYGB. The 4 multidisciplinary invitees included 1 minimally invasive/acute care surgeon, 1 tertiary abdominal radiologist, 1 gastroenterologist performing advanced endoscopy, and 1 general surgeon with expertise in synoptic reporting. Round 1 achieved an 83.3% (10/12) response and identified 91 potential items for consideration. Round 2 had a 100% response, and 69 items reached inclusion consensus. The third round achieved a 100% response and resulted in 75 QIs reaching final inclusion consensus. CONCLUSION: This study established consensus-derived multidisciplinary QIs for LRYGB operative reports. This will allow further assessment of the quality of narrative reports and afford the development of a synoptic operative report that may ameliorate identified deficiencies.

Does ultrasongraphy predict intraoperative findings at cholecystectomy? An institutional review.

BACKGROUND: Ultrasonography (US) is the mainstay of biliary tract imaging, but few recent studies have tested its ability to diagnose acute cholecystitis (AC). Our objective was to determine how well a US diagnosis of AC correlates with the intraoperative diagnosis. We hypothesize that US underestimates this diagnosis, potentially leading to unexpected findings in the operating room (OR). METHODS: This retrospective review included all patients admitted to the acute care surgical service of a tertiary hospital in 2011 with suspected biliary pathology who underwent US and subsequent cholecystectomy. We determined the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of US using the intraoperative diagnosis as the gold standard. Further analysis identified which US findings were most predictive of an intraoperative diagnosis of AC. We used a recursive partitioning method with random forests to identify unique combinations of US findings that, together, are most predictive of AC. RESULTS: In total, 254 patients underwent US for biliary symptoms; 152 had AC diagnosed, and 143 (94%) of them underwent emergency surgery (median time to OR 23.03 hr). Ultrasonography predicted intraoperative findings with a sensitivity of 73.2%, specificity of 85.5% and PPV of 93.7%. The NPV (52.0%) was quite low. The US indicators most predictive of AC were a thick wall, a positive sonographic Murphy sign and cholelithiasis. Recursive partitioning demonstrated that a positive sonographic Murphy sign is highly predictive of intraoperative AC. CONCLUSION: Ultrasonography is highly sensitive and specific for diagnosing AC. The poor NPV confirms our hypothesis that US can underestimate AC.

CONTEXTE: L'échographie est la pierre angulaire de l'imagerie des voies biliaires, mais peu d'études récentes ont vérifié sa capacité de diagnostiquer la cholécystite aiguë (CA). Notre objectif était de déterminer dans quelle mesure le diagnostic échographique de la CA est en corrélation avec son diagnostic peropératoire. Selon notre hypothèse, l'échographie sous-estime ce diagnostic, ce qui pourrait entraîner des résultats inattendus au bloc opératoire. MÉTHODES: Cette revue rétrospective a inclus tous les patients admis en 2011 au service chirurgical d'urgence d'un hôpital de soins tertiaires pour une pathologie biliaire présumée et qui ont subi une échographie, suivie d'une cholécystectomie. Nous avons déterminé la sensibilité, la spécificité, la valeur prédictive positive (VPP) et la valeur prédictive négative (VPN) de l'échographie, avec le diagnostic peropératoire comme base de référence. Une analyse plus approfondie a permis d'établir quels paramètres échographiques étaient les plus prédictifs d'un diagnostic peropératoire de CA. Nous avons utilisé la méthode de partitionnement récursif avec forêts aléatoires pour recenser les différents paramètres échographiques qui, ensemble, permettent le mieux de prédire la CA. RÉSULTANTS: En tout, 254 patients ont subi une échographie pour des symptômes biliaires; 152 ont reçu un diagnostic de CA et 143 ont subi une intervention chirurgicale d'urgence (temps médian avant l'arrivée au bloc opératoire 23,03 h). L'échographie a permis de prédire le diagnostic peropératoire avec une sensibilité de 73,2 %, une spécificité de 85,5 % et une VPP de 93,7 %. La VPN (52,0 %) était plutôt faible. Les paramètres échographiques les plus prédictifs de la CA sont une paroi épaisse, un signe de Murphy échographique positif et la cholélithiase. Le partitionnement récursif a démontré qu'un signe de Murphy échographique positif est une solide prédicteur de la CA peropératoire. CONCLUSION: L'échographie est hautement sensible et spécifique pour le diagnostic de la CA. La piètre VPN confirme notre hypothèse selon laquelle l'échographie pourrait sous-estimer la CA.