A cognitive task analysis of expert surgeons performing the robotic roux-en-y gastric bypass.

BACKGROUND: The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1) define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2) create a framework upon which training and objective evaluation of a RRNY can be based. METHODS: Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed. RESULTS: A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5 years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion, judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling). CONCLUSION: This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices.

Revisions after failed gastric band: sleeve gastrectomy and Roux-en-Y gastric bypass.

INTRODUCTION: Laparoscopic gastric band is an appealing bariatric operation due to its simplicity and good short-term outcomes; however, it is associated with complications (slippage, erosion, prolapse) and failure in reaching target weight loss. This study describes our experience with failed gastric bands that required a revisional procedure. MATERIALS AND METHODS: This single-center retrospective analysis includes all consecutive patients who underwent a gastric band removal and revisional surgery in our hospital from January 2008 to June 2014. A total of 81 patients were identified and divided in three groups: Group one included patients who just had the gastric band removed (43), group two consisted of patients who underwent a conversion to sleeve gastrectomy (SG) (26), and group three included patients who required a conversion to Roux-en Y gastric bypass (RYGB) (12). Patient demographics, date of gastric band placement, indications for revision, postoperative morbidity and mortality, operating time, blood loss, length of stay, and % excess weight loss (%EWL) were recorded. Perioperative and clinical outcomes were compared between conversions to SG and RYGB. RESULTS: In group two (n = 26), 21 conversions to SG were performed in concurrence with the band removal as a one-stage operation, while five procedures were performed in two-stages. There were no complications and no case was converted to open. Patients who underwent a one-stage procedure had a longer operative time, although it did not reach statistical significance. In group three, 12 patients underwent a conversion to RYGB as a revisional operation; 11 were performed as a one-stage procedure and only one patient underwent a two-stage procedure. CONCLUSIONS: SG and RYGB are safe options to revise a failed gastric band. Both groups who received either a SG or RYGB had a low complication rate and acceptable %EWL with no statistical difference between the two.

Bariatric surgery efficacy in patients with mood disorders.

BACKGROUND: Mood disorders are comorbid in patients with obesity and found in approximately 22.0% to 54.8% of patients who are eligible for bariatric surgery. Given the unclear effect of mood disorders on bariatric surgery outcomes, we aimed this study to assess the impact of mood disorders index bariatric surgery weight loss outcomes. METHODS: A retrospective study institutional database of index bariatric surgery patients at University Hospitals Cleveland Medical Center between 2016 and 2018. The primary outcome of body mass index was followed over a 4-year period. The secondary outcomes measured were mortality and suicide rates. Mood disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, included depressive and bipolar disorders obtained from electronic medical records International Classification of Diseases, Tenth Revision, coding. RESULTS: A total of 790 patients underwent bariatric surgery between 2016 and 2018. Of these, 15 patients were excluded due to death in the postoperative period or insufficient weight loss data, and a total of 775 patients (620 women and 155 men) were included. Two hundred and ninety-five (38.1%) had an electronic medical record mood disorder diagnosis before surgery, while 480 (61.9%) did not. Both groups had a significant decrease in postoperative body mass index; however, there was no significant difference in the body mass index change between the mood disorder group (mean = 37.63, standard deviation = 9.88) and the control group (mean = 38.72, standard deviation = 9.54; t[294] = 1.40; P = .1634). CONCLUSION: Patients with mood disorders are as successful with weight loss after index bariatric surgery as those without mood disorders. There was no significant difference in mortality rates between the mood disorder group and the control group. Hence, mood disorders should not be prohibitive for weight loss surgery.

Outcomes in racial minorities after robotic Roux-en-Y gastric bypass and sleeve gastrectomy: a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

BACKGROUND: The rate of robotic-assisted metabolic and bariatric surgery (MBS) is increasing. While discord remains about racial disparity in primary MBS, there are no data on robotic MBS outcomes in racial cohorts. OBJECTIVES: To determine whether outcomes following robotic-assisted Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are mediated by race or ethnicity. SETTING: University Hospital, United States. METHODS: Robotic RYGB and SG cases were identified from the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) databases using Current Procedure Terminology codes 43644, 43645, and 43775. Selected cases were stratified by race and ethnicity. Case-control matched and logistic regression analyses were performed. RESULTS: Matched analyses compared outcomes in 2666 RYGB cases of Black versus White patients and 1794 RYGB cases of Hispanic versus White patients. Black RYGB patients had longer operative lengths (OLs; P = .0008) and postoperative lengths of stay (P = .001), and a higher rate of pulmonary embolism (P = .05). Hispanic (versus White) RYGB patients had longer lengths of stay (P = .007). All other outcomes were similar between RYGB racial and ethnic cohorts. Matched analyses also compared outcomes of 8328 SG cases in Black versus White patients and 4852 SG cases in Hispanic versus White patients. Black patients had longer OLs (P = .004), had longer lengths of stay (P < .0001), had higher overall morbidity (P = .02), had higher bariatric-related morbidity (P = .02), had higher rates of readmission (P = .009), and were more likely to have an operative drain present at 30 days (P = .001). All other outcome measures were similar between racial/ethnic SG cohorts. CONCLUSION: Robotic-assisted SG is associated with higher overall and bariatric-related morbidity, but not mortality. However, robotic-assisted RYGB and SG remain safe, with lower rates of mortality and morbidity.

Variations in bariatric surgical practice patterns between general and bariatric surgeons: a matched analysis of the 2017 MBSAQIP database.

BACKGROUND: While general surgeons (GSs) perform metabolic and bariatric surgery (MABS), these procedures are increasingly performed by metabolic and bariatric surgeons (MBSs). Because MABS is an evolving practice with changing surgical platforms and approaches, it is important to evaluate outcomes between different specialists performing these procedures. OBJECTIVES: To compare perioperative practice pattern variations and outcomes of MABS performed by GSs versus MBSs. SETTING: University Hospital, United States. METHODS: Using the 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases and stratified them by specialization (GSs versus MBSs). Patient characteristics, practice patterns and outcomes, complications, and 30-day outcomes were compared between cohorts. Matched procedure-specific analyses were performed. RESULTS: Of 172,430 MABS procedures, 4394 (2.5%) were performed by GSs and 168,036 (97.4%) by MBSs. At baseline, patients of GSs had fewer co-morbidities. GSs more commonly used the robotic platform for SG cases and performed interventions such as staple line reinforcement and staple line check with provocative testing. MBSs more commonly performed robotic (versus laparoscopic) RYGB. Overall complications were low in both study cohorts. After propensity matching, transfusion and venous thromboembolism were higher in SG performed by GSs, while surgical site infection was higher in SG and RYGB performed by MBSs. These findings were not reproduced after case-control matching. In matched analyses, there were no mortality or morbidity differences between study cohorts. CONCLUSION: MABS is performed safely by both GSs and MBSs, with no difference in morbidity and mortality.

Outcomes in racial and ethnic minorities after revisional robotic-assisted metabolic and bariatric surgery: an analysis of the MBSAQIP database.

BACKGROUND: Robotic-assisted metabolic and bariatric surgery (MBS) is being performed with increased frequency in the United States, including for revisional MBS. However, little is known about perioperative outcomes between racial and ethnic cohorts after revisional robotic-assisted MBS. OBJECTIVE: The goal of our study was to determine if there are racial differences in outcomes after robotic-assisted revisional MBS. SETTING: University Hospital, United States. METHODS: Using the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified patients undergoing revisional MBS by a robotic-assisted approach. Univariate analyses were performed of unmatched and matched racial and ethnic cohorts, comparing black versus white patients and Hispanic versus white patients. RESULTS: Of 2027 robotic-assisted revisional MBS cases in the database, 1922 were included in our analysis, including 67%, 22.6%, and 10.4% white, black, and Hispanic patients, respectively. At baseline, there were some differences in patient characteristics between racial and ethnic cohorts. After propensity matching, outcomes between black and white patients were similar, except for higher rates of superficial surgical site infection among white patients (P = .05) and higher rates of organ space surgical site infection in black patients (P = .05). Outcomes were also similar between matched white and Hispanic patients, except for a higher bleeding in white patients (2% versus 0%, P = .04). There were no mortality or morbidity differences between racial and ethnic cohorts. CONCLUSION: Morbidity and mortality after robotic-assisted revisional MBS do not seem to be mediated by race or ethnicity.

Albumin Protein Cleavage Affects the Wear and Friction of Ultra-High Molecular Weight Polyethylene.

It is well established that the total protein concentration and albumin-to-globulin ratio influence the wear of ultra-high molecular polyethylene (UHMWPE, "polyethylene") in joint prostheses. A factor on wear not yet studied, but of possible clinical relevance, is protein cleavage. Such cleavage is expected in the presence of an inflammatory response and as a result of wear processes at the articular interface. The aim of this study was to compare the tribological behavior of polyethylene articulated against an orthopedic wrought CoCrMo alloy for three lubricants: cleaved albumin, uncleaved albumin, and newborn calf serum (control). We hypothesized that the cleavage of albumin will increase the friction and wear rate of polyethylene, with a concomitant roughening of the polymer surface and the generation of larger wear debris particles. Cleavage of the bovine albumin into five fragments was performed by digestion with cyanogen bromide. In pin-on-flat (POF) wear tests of polyethylene pins made of Ticona GUR® 1020/1050 against CoCrMo alloy discs, the cleaved albumin led to the lowest polyethylene wear and highest friction coefficients, whereas albumin led to the highest wear rates. In knee simulator tests, the albumin lubricant also led to a 2.7-fold increase in the tibial insert wear rate compared to the regular bovine serum lubricant (a wear rate for the cleaved albumin could not be obtained). The generated polyethylene wear particles were of increasing size and fibrillar shape in going from serum to albumin to cleaved albumin, although only the shape achieved statistical significance. Unlike bovine serum, cleaved albumin led to wear scars for both the POF and simulator wear tests that closely emulated the morphological features observed on explanted polyethylene tibial inserts from total knee replacements. We posit that the smaller protein fragments can more efficiently adsorb on the surfaces of both the polyethylene and the metal, thus offering protection against wear, while at the same time leading to an increase in friction, particle size, and particle elongation, as the protein fragment films interact adhesively during sliding. The results of this study have implications for pre-clinical wear testing methodology as they suggest that albumin concentration may be more pertinent than total protein concentration for wear testing polyethylene.

Laparoscopic and robotic sleeve gastrectomy: short- and long-term results.

INTRODUCTION: Sleeve gastrectomy has gained popularity over the past decade due to its safety, feasibility, and good results. The purpose of this study is to describe our results, both short and long term, with this procedure. MATERIAL AND METHODS: This study is a nonrandomized, controlled, retrospective review of 409 patients who underwent a minimally invasive sleeve gastrectomy at the University of Illinois Hospital and Health System from January 2008 to December 2013. A total of 304 patients underwent a laparoscopic sleeve gastrectomy, and another 105 patients underwent a robotic procedure using the da Vinci Surgical System®. Patient demographics, comorbidities, date of surgery, postoperative morbidity and mortality, operating time, length of stay, and excess weight loss were reviewed. RESULTS: The mean age was 41 years (18-70) with no statistical difference between the two groups. Patient's demographics were similar (p = 0.395) in both groups. The mean operative time for the robotic group was 110.6 versus 84.18 min in the laparoscopic group, which was statistically significant (p < 0.05). There were no significant differences between the two groups with regard to the perioperative complications, length of stay, or % excess weight loss. CONCLUSION: There is no significant difference between the robotic and laparoscopic group in terms of complications, length of stay, and estimated blood loss. Robot-assisted sleeve gastrectomy is associated with longer operative time and increased cost.