Validity and interrater reliability of a regional mock oral board examination.

BACKGROUND: There have been decreasing pass rates recently on the American Board of Surgery Certifying Examination (ABSCE). General surgery residents from the University of Pittsburgh Medical Center, the West Penn Allegheny Health System, the Conemaugh Health System, and Mercy Hospital participate in a mock oral board examination, which is similar to the ABSCE. The aims of the study are to compare examinee performance on the mock oral boards with the ABSCE and to evaluate the interrater reliability of examiner pairs. METHODS: In this retrospective study from 2003 to 2010, outcomes on the mock oral boards and the first attempt of the ABSCE for chief residents were compared for the 4 regional residency programs. Interrater reliability for examiner pairs was evaluated with agreement and kappa statistics. Nonparametric statistics were performed, with α = 0.05. RESULTS: A total of 32 of 38 (84.2%) chief residents passed the mock oral boards. The median score for each of the 3 rooms was 6 (clear pass). A total of 37 of 38 (97.4%) residents passed the ABSCE. The sensitivity of the mock oral boards was 83.8%, with a positive predictive value of 96.9%, and an accuracy of 81.6%. A total of 25 of 47 (53.2%) examiner pairs were from the same residency institution, whereas 22 of 47 (46.8%) were from different institutions. The median agreement was 100% (interquartile range (IQR) [100% - 100%]). The median kappa statistic was 1.00 (IQR [0.38-1.00]). The Mann-Whitney U tests showed no difference in agreement or kappa for examiner pairs from the same or from different institutions (p> 0.05). CONCLUSIONS: The mock oral boards have substantial sensitivity and positive predictive value in relation to the ABSCE. There are also very high levels of interrater agreement and interrater reliability. This regional mock oral board examination is valuable for ABSCE preparation.

Experimental model of laparoscopic gastric ischemic preconditioning prior to transhiatal esophagectomy.

BACKGROUND: Cervical esophagogastric anastomotic disruption following transhiatal esophagectomy (THE) is a significant problem. Gastric tip ischemia is a primary cause of anastomotic failure. We examined gastric tip blood flow when laparoscopic "ischemic preconditioning" was attempted by selectively ligating the short gastric (SG) vessels or both the left and short gastric (LG/SG) vessels prior to THE. METHODS: Seventeen (25 kg) mongrel dogs underwent laparoscopy followed 3 weeks later by THE. Three groups were studied: control group = laparoscopy only, no preconditioning (n = 6); SG group = laparoscopic ligation of SG vessels only (n = 5); and LG/SG group = laparoscopic ligation of LG and SG vessels (n = 6). Tissue blood flow was assessed using the fluorescent microsphere method. The initial microsphere injections occurred prior to pneumoperitoneum and upon completion of the laparoscopy. At the second operation, transhiatal esophagectomy was performed and microsphere blood flow assessment occurred after induction of anesthesia, after mobilization of the stomach, and after completion of the cervical esophagogastric anastomosis. The animals were euthanized and regional gastric tissue was analyzed for microsphere estimates of blood flow. Differences in blood flow were evaluated using Student's t test. RESULTS: The mean baseline gastric blood flow was 0.58 ml/min/g. After THE, the proximal gastric blood flow fell to 16% of baseline in control and 22% in SG, but was reduced to only 60% of baseline in LG/SG. This relative preservation of blood flow among the LG/SG group approached significance compared with the laparoscopy-only (control) group (P = 0.07). Ligation of SG vessels alone provided no preservation of proximal gastric blood flow following THE. CONCLUSION: Preoperative "ischemic preconditioning" through ligation of both the short and left gastric vessels may achieve preservation of blood flow to the gastric tip. Preconditioning during laparoscopic staging of esophageal carcinoma may be considered to reduce anastomotic complications following esophagectomy.

Laparoscopic revision of vertical banded gastroplasty to Roux-en-Y gastric bypass: outcomes of 105 patients.

BACKGROUND: Although vertical banded gastroplasty (VBG) was endorsed by the 1991 National Institutes of Health Consensus Conference for the treatment of morbid obesity, it has largely been abandoned owing to the poor long-term weight loss and band-related complications. The objective of the present study was to review the outcomes of patients who had undergone laparoscopic conversion of VBG to Roux-en-Y gastric bypass (RYGB) for weight loss or dysphagia and gastroesophageal reflux. METHODS: A retrospective review of prospectively collected data from all patients who had undergone revision of VBG to RYGB was performed. The data on the symptoms, weight loss, co-morbidities, and complications were collected. RESULTS: From July 1999 to April 2010, 2397 bariatric procedures were performed. Of these, 105 (4.4%) were laparoscopic revisions of previous VBG to RYGB. Of the 105 patients, 103 had undergone open VBG and 2 laparoscopic VBG. Of the 105 patients, 97 were women and 8 were men. The average patient age was 49 years (range 23-71). The median preoperative body mass index was 42 kg/m(2) (range 20-72). Short- and long-term complications occurred in 40 patients (38%). No patients died. The median length of stay was 2 days. At an average follow-up of 31 months (range 1-96), the median percentage of excess weight loss was 47% (range -24% to 138%). The median decrease in body mass index was 8 kg/m(2) (range -6 to 30). Dysphagia had improved or resolved in 100%. Gastroesophageal reflux disease had improved or resolved in 95%. Diabetes had improved or went into remission in 90%. Hypertension had improved or resolved in 62%. Obstructive sleep apnea had improved or resolved in 96%. CONCLUSION: The results of our study have shown that laparoscopic revision of VBG to RYGB is a feasible procedure that can provide acceptable weight loss and reversal of weight-related co-morbidities. Complications were common after revisional bariatric surgery.

Technical skills assessment as part of the selection process for a fellowship in minimally invasive surgery.

INTRODUCTION: Selection of candidates for surgical fellowships has traditionally been based on subjective evaluations by the program directors and references from previous positions. The introduction of well-validated objective methods of assessment has allowed us to evaluate candidates' technical skills and base the selection process on objective, reliable, and transparent criteria. The aim of the study was to assess the applicability of such methods in current practice. MATERIALS AND METHODS: Prospective study. Eight surgeons, applying for a fellowship position in minimally invasive surgery (MIS), performed a previously validated assessment curriculum using a Virtual-Reality Laparoscopic Trainer (LapSim 3.0, Surgical Science, Gothenburgh, Sweden). Technical performance was evaluated using criteria registered by the simulator, i.e., time, error score, and efficiency of movements score. Candidates performed all the tasks in easy end medium level until reaching predefined criteria. If proficiency criteria were not achieved on easy or medium level after nine repetitions the test was considered as failed. Additionally, all applicants underwent an interview by two independent attending surgeons. Each applicant received a grade on a ten-point scale. RESULTS: Five out of the eight candidates failed the technical skills assessment test. One candidate failed to achieve proficiency criteria on easy level, one on medium, and three on difficult level. Evaluation scores, based on the interview of the candidates showed a good interrater reliability (Cronbach's alpha = 0.8). There was no significant correlation between the interviewers rating, and the applicants technical skills demonstrated during the test on the VR trainer (Spearman's rho = 0.182, p = 0.696). CONCLUSIONS: Evaluations by senior surgeons are reproducible and reliable. The introduction of technical skills assessment has the potential to improve the current method of candidate selection, making it more valid, objective, and transparent.

Effect of immunosuppression on patients undergoing bariatric surgery.

BACKGROUND: Immunocompromised patients are at high risk of medical complications. Immunosuppression might be a relative contraindication to bariatric surgery. We describe our experience with immunosuppressed patients undergoing bariatric surgery and review the safety, efficacy, results, and outcomes. METHODS: We performed a retrospective review of prospectively collected data. All patients taking long-term immunosuppressive medications or with a diagnosis of an immunosuppressive condition were included in this study. Data on weight loss, co-morbidities, complications, and postoperative immunosuppression were collected. RESULTS: From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 61 (3.9%) were taking immunosuppressive medications or had an immunosuppressive condition. Of these 61 patients, 49 were taking immunosuppressive medications for asthma, autoimmune disorders, endocrine deficiency, or chronic inflammatory disorders. The medications included oral, inhaled, and topical glucocorticoids for 39 patients and other immunosuppressive or disease-modifying antirheumatic drugs for 24 patients. The bariatric procedures included laparoscopic Roux-en-Y gastric bypass in 55, laparoscopic revisional procedures in 5, and laparoscopic sleeve gastrectomy in 1. No patient died perioperatively. A total of 26 complications occurred in 20 patients. The average percentage of excess weight loss was 72% (range 20-109%) at 1 year postoperatively. At a median postoperative follow-up of 18 months (range 2-68.6), 25 (51%) of 49 patients no longer required immunosuppressive medications owing to improvement of their underlying disease. Obesity-related health problems (diabetes mellitus, hypertension, obstructive sleep apnea, gastroesophageal reflux disease, asthma) had resolved or improved in 80-100% of patients. CONCLUSION: The results of our study have shown that immunocompromised patients can safely undergo bariatric surgery with good weight loss results and improvement in co-morbidities. A large percentage of patients were able to discontinue immunosuppressive medications postoperatively.

Obesity surgery and malignancy: our experience after 1500 cases.

BACKGROUND: Obesity is a risk factor for cancer and is associated with increased mortality from a number of malignancies. We describe our experience with bariatric surgery patients with a history of malignancy and review the safety and outcomes of bariatric surgery in patients with a history of cancer. METHODS: We performed a retrospective review of prospectively collected data from all patients diagnosed with a malignancy before, during, or after bariatric surgery. Data on weight loss, co-morbidities, and recurrence were collected. RESULTS: From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 36 (2.3%) had a history of malignancy before they underwent bariatric evaluation and surgery, 4 (0.26%) were diagnosed with a malignancy during their preoperative evaluation, 2 of whom subsequently underwent bariatric surgery, and 2 had intraoperative findings suspicious for malignancy; bariatric surgery was completed in both cases. The evaluation revealed renal cell carcinoma and low-grade lymphoma, respectively. No procedures were aborted because of a suspicion of malignancy. Postoperatively, 16 patients (0.9%) were diagnosed with cancer, 3 of whom had a history of malignancy: 1 with metastatic renal cell, 1 with recurrent melanoma, and 1, who had had prostate cancer, with bladder cancer. CONCLUSION: A history of malignancy does not appear to be a contraindication for bariatric surgery as long as the life expectancy is reasonable. Screening for bariatric surgery might reveal the malignancy. Bariatric surgery does not seem to have a negative effect on the treatment of malignancies that are discovered in the postoperative period.

Prevalence of Helicobacter pylori infection and value of preoperative testing and treatment in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Previous studies have reported a high prevalence of Helicobacter pylori infection in patients undergoing Roux-en-Y gastric bypass (RYGB) and a greater incidence of anastomotic ulcer in patients positive for H. pylori, leading to recommendations for routine preoperative screening. Our hypotheses were that the prevalence of H. pylori in patients undergoing RYGB is similar to that of the general population and that preoperative H. pylori testing and treatment does not decrease the incidence of anastomotic ulcer or pouch gastritis. METHODS: A retrospective analysis of H. pylori serology, preoperative and postoperative endoscopy findings, and the development of anastomotic ulcer or erosive pouch gastritis was performed. All patients positive for H. pylori received treatment. Univariate parametric and nonparametric statistical tests, as well as multiple logistic regression analyses, were performed. RESULTS: A total of 422 LRYGB patients were included in the study. Of these patients, 259 (61.4%) were tested for H. pylori and 163 (38.6%) were not. Of the 259 patients, 58 (22.4%) tested positive for H. pylori, 197 (76.1%) tested negative, and 4 (1.5%) had an equivocal result. Postoperatively, 53 patients (12.6%) underwent upper endoscopy. Of these 53 patients, 19 (4.5%) had positive endoscopy findings for anastomotic ulcer (n = 16) or erosive pouch gastritis (n = 3). Five patients underwent biopsy at endoscopy; all biopsies were negative for H. pylori. No difference was found in the rate of positive endoscopy between patients tested preoperatively for H. pylori (5%) and patients not tested (3.7%). CONCLUSION: The results of our study have shown that the prevalence of H. pylori infection in patients undergoing RYGB is similar to that of the general population. Our study has shown that H. pylori testing does not lower the risk of anastomotic ulcer or pouch gastritis.

Intraoperative death due to thrombotic thrombocytopenic purpura (TTP)-related acute myocardial failure in a patient undergoing laparoscopic splenectomy.

Thrombotic thrombocytopenic purpura (TTP) is an uncommon disorder characterized by a pentad of microangiopathic hemolytic anemia, thrombocytopenia, renal dysfunction, fever, and a fluctuating neurologic syndrome. Splenectomy is performed for patients who are refractory to plasma therapy and for relapsing TTP. We describe a case of a patient who died due to intramyocardial hemorrhage after undergoing laparoscopic splenectomy for TTP resistant to treatment with plasmapheresis. A 52-year-old woman was admitted with ecchymoses, low platelet count, weakness of left face and upper extremity, and a presumptive diagnosis of TTP. Vital signs were stable. White blood count was 7800/microL, hemoglobin 7.9 g/dL, and platelet count of 13,000/microL. Her basic metabolic panel and liver function tests were normal. Further laboratory workup confirmed the diagnosis of TTP. The patient was initially treated with plasmapheresis and high dose steroid therapy but underwent an emergent laparoscopic splenectomy due to refractory TTP. At the end of the uneventful procedure, the patient suffered a cardiac arrest and died. Autopsy concluded that the death was from myocardial failure due to extensive myocardial hemorrhage secondary to TTP. There are several published case reports of sudden death due to cardiac involvement in TTP. However, intraoperative mortality is not reported. We conclude that TTP-related acute heart failure may represent an extremely important clinical risk in these patients who are undergoing surgery.

Pulmonary considerations in obesity and the bariatric surgical patient.

Severe obesity can be associated with significant alterations in normal cardiopulmonary physiology. The pathophysiologic effects of obesity on a patient's pulmonary function are multiple and complex. The impact of obesity on morbidity and mortality are often underestimated. Bariatric surgery has been shown to be the most effective modality of reliable and durable treatment for severe obesity. Surgical weight loss improves and, in most cases, completely resolves the pulmonary health problems associated with obesity.

Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass.

BACKGROUND: Access and endoscopic evaluation of the bypassed stomach is difficult after laparoscopic Roux-en-Y gastric bypass. We propose a minimally invasive technique to access the bypassed stomach after Roux-en-Y gastric bypass for endoscopic diagnosis and treatment. METHODS: First, we established carbon dioxide pneumoperitoneum to a pressure of 12-15 mm Hg. Next, 12-mm umbilical, 5-mm right upper quadrant, 5-mm left lower quadrant, and 15-mm left upper quadrant trocars were placed. A purse-string suture was placed on the anterior wall of the stomach. A gastrotomy was made using ultrasonic shears and the 15-mm trocar was placed into the stomach. The endoscope was then inserted through the 15-mm trocar, and the pneumoperitoneum was decreased to 10 mm Hg. Once the evaluation was complete, the gastrotomy was closed with a running suture or linear stapler. RESULTS: Ten patients at our institution have undergone laparoscopic transgastric endoscopy. Five patients had biliary pathologic findings. Four of these patients underwent successful endoscopic retrograde cholangiopancreatography and papillotomy; the procedure in the fifth patient was unsuccessful because stone impaction at the ampulla. Three patients were evaluated for gastrointestinal bleeding. One was diagnosed with a duodenal gastrointestinal stromal tumor, one with a bleeding duodenal ulcer, requiring surgical exploration; and the third had negative endoscopy findings. Two patients evaluated for chronic abdominal pain had negative endoscopy findings. No complications developed. CONCLUSIONS: Laparoscopic transgastric endoscopy is a safe and minimally invasive approach for the evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergone Roux-en-Y gastric bypass.

Percutaneous computed tomography-guided gastric remnant access after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The bypassed portion of the stomach is difficult to access and evaluate after Roux-en-Y gastric bypass. Access to the excluded stomach may be needed for nutritional support or decompression owing to acute distension and obstruction. We report our experience with percutaneous, computed tomography (CT)-guided gastrostomy tube placement into the gastric remnant after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Of 569 consecutive LRYGB procedures performed, 9 patients underwent successful percutaneous, CT-guided gastrostomy placement. One additional patient was referred from another facility. We reviewed the indications, interval from surgery to the intervention, interval to removal, complications, and success or outcome of the procedure in our patient population. RESULTS: Ten patients underwent percutaneous, CT-guided gastric remnant gastrostomy tube placement. The indications included distended gastric remnant in 6, nutritional access in 4, and remnant drainage after leak in 1. Of the 10 patients, 2 had undergone previous gastric operations. The attempt at percutaneous gastrostomy was unsuccessful in 1 additional patient, who subsequently required laparoscopic gastrostomy (success rate 91%). CONCLUSION: In selected patients after LRYGB, CT-guided gastrostomy tube placement is safe and efficient. It may be used to manage complications of LRYGB, serve as a bridge to definitive surgery, or offer a convenient route for enteral nutritional support.

Laparoscopic resection of gastric diverticulum presenting after Roux-en-Y gastric bypass.

Gastric diverticula are extremely rare and may be congenital or acquired. Postgastrectomy formation of gastric diverticula has been attributed to outpouching through the weakened wall of the stomach. When symptomatic, gastric diverticula may cause pain, nausea, dysphagia, and vomiting. Gastric diverticula may also be associated with ectopic mucosa, ulcers, and neoplastic changes. We report a case of gastric cardia diverticulum that became symptomatic after laparoscopic Roux-en-Y gastric bypass. The patient was successfully treated with laparoscopic resection.

Routine gallbladder screening not necessary in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Management of the gallbladder in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) is controversial. We reviewed our experience in patients undergoing LRYGBP without routine gallbladder screening. METHODS: The data of 644 patients who underwent LRYGBP at our institution were analyzed. Preoperative ultrasonography was routinely obtained early in our series and selectively thereafter in patients with suspected symptomatic biliary disease. Cholecystectomy at LRYGBP was performed in symptomatic patients with positive ultrasound findings. Postoperatively, patients with intact gallbladders were prescribed ursodiol for 6 months. RESULTS: Of the 644 patients, 155 (24%) had history of cholecystectomy. A total of 104 patients underwent preoperative ultrasonography. Of the 104 patients, 20 had positive ultrasound findings and symptoms consistent with biliary disease and underwent concomitant cholecystectomy. Twelve patients had positive ultrasound findings and no biliary symptoms and did not undergo cholecystectomy. At a mean follow-up of 26.4 months, only 1 (8.3%) of the 12 patients had required cholecystectomy. Of the 104 patients, 72 had negative ultrasound findings. At a mean follow-up of 21.2 months, 5 of them (6.9%) had required cholecystectomy. The remaining 385 patients did not undergo any gallbladder screening. At a mean follow-up of 14 months, 32 (8.3%) of 385 patients had required cholecystectomy. Compliance with ursodiol for >4 months was only 39%. A time-to-event analysis did not reveal a significant difference in the cholecystectomy rate between asymptomatic patients with preoperative gallbladder screening and patients with no screening. CONCLUSION: Omission of gallbladder screening in asymptomatic patients undergoing LRYGBP is a reasonable approach that spares the patient a potentially unnecessary procedure with all its associated risks.

Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed operation for the treatment of morbid obesity in the USA. Complications related to the jejuno-jejunal (J-J) anastomosis include postoperative leak, staple-line bleeding and obstruction. We present 3 cases of perforation at the J-J anastomosis occurring more than 30 days after surgery. 3 morbidly obese patients underwent laparoscopic RYGBP. The side-to-side J-J anastomosis was created with a linear stapler, and the anastomotic defect was closed with a running absorbable suture. All 3 patients had uneventful recoveries, but presented 7 to 8 weeks postoperatively with acute abdominal pain and peritoneal signs. Exploratory laparoscopy in these patients revealed a perforation at the J-J anastomosis. No apparent reason for the perforation was found in 2 patients. These perforations were repaired laparoscopically with absorbable suture. The third patient had an obstruction at the J-J anastomosis from an phytobezoar and required conversion to open technique due to limited pneumoperitoneum. All 3 patients recovered uneventfully. Late perforation of the J-J anastomosis is a very rare complication. Primary laparoscopic repair is a feasible and safe choice of treatment.

Laparoscopic Roux-En-Y gastric bypass is a safe and effective operation for the treatment of morbid obesity in patients older than 55 years.

BACKGROUND: Bariatric surgery in patients >50 years has been controversial. We investigated the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients >55 years of age. METHODS: Prospective data on 71 patients (54 females and 17 males) undergoing LRYGBP were reviewed. The patients were followed for a mean of 17 months (range 2-35 months). RESULTS: The mean age was 59 years (range 55-67 years), and the mean preoperative BMI was 50.2 kg/m2 (range 37-65 kg/m2). There were no conversions to open technique. Mean percent of excess weight loss (%EWL) was 20%, 48%, 64% and 67% at 1, 6, 12 and 24 months respectively. 89% of patients had at least a 50% EWL at 1 year postoperatively. There was a significant decrease in the number of patients requiring medical treatment for co-morbidities associated with morbid obesity: diabetes mellitus 87%, hypertension 70% and sleep apnea 86%. There was no inpatient mortality. 1 patient died suddenly 2 weeks postoperatively of possible myocardial infarction or pulmonary embolism. 16 patients developed 22 complications. The median length of hospital stay was 3 days. CONCLUSION: LRYGBP is a safe and well-tolerated surgical option for the treatment of morbid obesity in patients >55 years old. These patients demonstrate a satisfactory weight loss and resolution of co-morbidities.