Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life.

BACKGROUND: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties. METHODS: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies. RESULTS: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic). CONCLUSIONS: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

Predictors of Robotic Versus Laparoscopic Inguinal Hernia Repair.

BACKGROUND: The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR). METHODS: We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression. RESULTS: The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05). CONCLUSIONS: The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.

Predictors of laparoscopic versus open inguinal hernia repair.

BACKGROUND: Inguinal hernia repair (IHR) is among the most common general surgery procedures. Multiple studies have examined costs and benefits of laparoscopic approach versus open repair. This study aimed to identify patient, surgeon, and hospital demographic predictors of laparoscopic versus open IHR. METHODS: We conducted a retrospective analysis of 342,814 IHRs (241,669 open; 101,145 laparoscopic) performed in adults (age ≥ 18) from 2010 to 2015 using the Premier Hospital Database. Multivariate logistic regression was used to estimate the adjusted odds ratio of an IHR being laparoscopic versus open with respect to several demographic variables. RESULTS: The odds of an IHR being laparoscopic increased from 2010 to 2015. A laparoscopic procedure was more likely in patients who were < age 65 (OR 1.29, CI 1.24-1.31, p < 0.0001), male (OR 1.31, CI 1.27-1.34, p < 0.0001), privately insured (OR 1.36, CI 1.33-1.40, p < 0.0001), and neither white, black, nor Hispanic (OR 1.11, CI 1.09-1.14, p < 0.0001). The likelihood of a procedure being laparoscopic decreased 13% with each one-unit increase in Charlson comorbidity index value (OR 0.88, CI 0.87-0.89, p < 0.0001). Surgeons were more likely to perform a laparoscopic procedure if they had larger annual IHR caseloads (≥ 45/year; OR 1.57, CI 1.53-1.60, p < 0.0001), and operated at large hospitals (> 500 beds; OR 1.36, CI 1.33-1.39, p < 0.0001) in New England (OR 2.38, CI 2.29-2.47, p < 0.0001). Non-predictors of a laparoscopic procedure included urban/rural hospital location (OR 1.02, CI 0.10-1.05, p = 0.06) and hospital teaching status (OR 1.01, CI 0.99-1.03, p = 0.2084). CONCLUSIONS: Use of laparoscopic IHR is increasing. Patient age, gender, race, and insurance type, as well as surgeon annual volume, hospital size, and hospital region were predictors of a laparoscopic procedure. Further studies are needed to explain and remedy underlying differences impacting these predictors.

Impact of minimally invasive surgery on healthcare utilization, cost, and workplace absenteeism in patients with Incisional/Ventral Hernia (IVH).

BACKGROUND: Incisional hernia repair is one of the most common general surgery operations being performed today. With the advancement of laparoscopy since the 1990s, we have seen vast improvements in faster return to normal activity, shorter hospital stays and less post-operative narcotic use, to name a few. OBJECTIVE: The key aims of this review were to measure the impact of minimally invasive surgery versus open surgery on health care utilization, cost, and work place absenteeism in the patients undergoing inpatient incisional/ventral hernia (IVH) repair. METHODS: We analyzed data from the Truven Health Analytics MarketScan® Commercial Claims and Encounters Database. Total of 2557 patients were included in the analysis. RESULTS: Of the patient that underwent IVH surgery, 24.5% (n = 626) were done utilizing minimally invasive surgical (MIS) techniques and 75.5% (n = 1931) were done open. Ninety-day post-surgery outcomes were significantly lower in the MIS group compared to the open group for total payment ($19,288.97 vs. $21,708.12), inpatient length of stay (3.12 vs. 4.24 days), number of outpatient visit (5.48 vs. 7.35), and estimated days off (11.3 vs. 14.64), respectively. At 365 days post-surgery, the total payment ($27,497.96 vs. $30,157.29), inpatient length of stay (3.70 vs. 5.04 days), outpatient visits (19.75 vs. 23.42), and estimated days off (35.71 vs. 41.58) were significantly lower for MIS group versus the open group, respectively. CONCLUSION: When surgical repair of IVH is performed, there is a clear advantage in the MIS approach versus the open approach in regard to cost, length of stay, number of outpatient visits, and estimated days off.

The subspecialization of surgery: a paradigm shift.

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by "specialists". The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Weight loss interventions for morbidly obese patients with compensated cirrhosis: a Markov decision analysis model.

Many transplant centers require that patients maintain a BMI below 40 kg/m(2) in order to be eligible for listing, rendering many morbidly obese patients with end-stage liver disease unable to access liver transplantation as a method of treatment. In order to determine the safest and most efficacious weight loss regimen in this challenging population, Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and diet and exercise were modeled to assess their impact on life expectancy in morbidly obese patients with cirrhosis. A Markov state transition model was developed to assess the survival benefit of undergoing RYGB, AGB, or 1 year of diet and exercise in morbidly obese patients with compensated cirrhosis. A base case analysis of no weight loss intervention in a 45-year-old patient with compensated cirrhosis and a BMI of 45 kg/m(2) revealed an average survival of 7.93 years. The average survival for the weight loss simulations was 9.14, 8.84, and 8.16 years for RYGB, AGB, and diet and exercise, respectively. In morbidly obese patients with compensated cirrhosis, RYGB allows patients to lose more weight more rapidly than is probable with either AGB or diet and exercise, thus having the greatest impact on survival.

Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: a decision analysis.

BACKGROUND: The optimal management of morbidly obese patients awaiting renal transplant is controversial and unknown. The objective of this study was to compare the impact of Roux-en-Y gastric bypass (RYGB) versus diet and exercise on the survival of morbidly obese patients with end-stage renal disease awaiting renal transplant. METHODS: A decision analytic Markov state transition model was designed to simulate the life of morbidly obese patients with end-stage renal disease awaiting transplant. Life expectancy after RYGB and after 1 and 2 years of diet and exercise was estimated and compared in the framework of 2 clinical scenarios in which patients above a body mass index (BMI) of 35 kg/m(2) or above a BMI of 40 kg/m(2) were ineligible for transplantation, reflecting the BMI restrictions of many transplant centers. In addition to base case analysis (45 kg/m(2) BMI preintervention), sensitivity analysis of initial BMI was completed. Markov model parameters were extracted from the literature. RESULTS: RYGB improved survival compared with diet and exercise. Patients who underwent RYGB received transplants sooner and in higher frequency. Using 40 kg/m(2) as the upper limit for transplant eligibility, base case patients who underwent RYGB gained 5.4 years of life, whereas patients who underwent 1 and 2 years of diet and exercise gained 1.5 and 2.8 years of life, respectively. Using 35 kg/m(2) as the upper limit, RYGB base case patients gained 5.3 years of life, whereas patients who underwent 1 and 2 years of diet and exercise gained .7 and 1.5 years of life, respectively. CONCLUSIONS: In morbidly obese patients with end-stage renal disease, RYGB may be more effective than optimistic weight loss outcomes after diet and exercise, thereby improving access to renal transplantation.

Bariatric surgery outcomes.

Obesity is associated with an increased risk of death, and morbid obesity carries a significant risk of life-threatening complications such as heart disease, diabetes, and high blood pressure. Bariatric surgery is recognized as the only effective treatment of morbid obesity. The estimated number of bariatric operations performed in the United States in 2008 was more than 13 times the number performed in 1992. Despite this increase, only 1% of the eligible morbidly obese population are currently treated with bariatric surgery.

Laparoscopic gastrostomy and jejunostomy.

BACKGROUND: The percutaneous/endoscopic gastrostomy (PEG) has rapidly replaced the surgical gastrostomy as the preferred route for enteral access. In patients who are not candidates for a PEG, we prefer a laparoscopic gastrostomy to an open gastrostomy. Similarly, in patients who require a surgical jejunostomy, we prefer a laparoscopic approach. Minimally invasive techniques have several advantages over the standard open surgery. The purpose of this article is to review the indications, various techniques, and outcomes of laparoscopic gastrostomy and jejunostomy tubes. DATA SOURCES: Medline search from 1959-2002. CONCLUSIONS: The PEG remains the procedure of choice for placement of a gastrostomy. Laparoscopic gastrostomy is an excellent choice for patients who are not candidates for a PEG. Similarly, laparoscopic jejunostomy is an excellent choice for patients who require enteral access, but have contraindications to a gastrostomy tube. Placement of laparoscopic gastrostomy andjejunostomy tubes can be safely performed, and the success and complication rates of these procedures compare favorably with those of the corresponding open surgical procedure. Laparotomy is rarely needed to place enteral feeding tubes. Cost analysis has shown that laparoscopic procedures are similar to open procedures.