Primary Care Physicians' Perceptions of Bariatric Surgery and Major Barriers to Referral.

BACKGROUND: Each year from 2011 to 2017, fewer than 1% of eligible Americans underwent bariatric surgery to treat obesity and obesity-related comorbidities. Recent studies have suggested that a lack of knowledge within the primary care specialty about the safety and efficacy of bariatric surgery greatly affects referral. This study aimed to analyze a large cohort of primary care physicians' (PCPs) clinical perceptions regarding bariatric surgery and to identify major barriers to referral that could inform the implementation of a future educational strategy to address underutilization of bariatric surgery. STUDY DESIGN: A prospective anonymous electronic survey was sent to all primary care physicians at a multicenter community-based academic hospital system between March and June of 2018, with 150 respondents, a response rate of 28%. The survey was composed of eleven questions in total, the first eight utilizing a five-point Likert scale, with answers including strongly disagree, disagree, neutral, agree, and strongly agree. The final three questions utilized freeform answers of numbers or text where appropriate. RESULTS: Between 83 and 88% of PCPs responded favorably, either agree or strongly agree, to questions regarding the utility of bariatric surgery as an efficacious and valuable tool for the treatment of obesity and related comorbidities. PCPs reported an average body mass index (BMI) of 40.4 ± 5.0 kg/m2 at which bariatric surgery is a patient's best option for weight loss and an average BMI of 38.0 ± 5.6 kg/m2 at which surgery is the best option for management of comorbidities. Eighty-six percent of PCPs agree that having a BMI over 40 kg/m2 is a greater risk to a patient's long-term health than undergoing bariatric surgery. However, only 46.6% of PCPs claimed any familiarity with the NIH eligibility criteria for bariatric surgery and only 59.5% responded affirmatively that they were comfortable participating in the long-term care of a postoperative bariatric patient. The two highest reported barriers to referral for bariatric surgery together account for 40% of PCPs responses: 21.5% of PCPs report concern regarding surgical complications and/or long-term side effects as the primary barrier for referral, and 18.5% report concern for ineffective weight loss after bariatric surgery as a primary barrier to referral. CONCLUSION: Results of this study indicate that despite largely positive attitudes toward the use of bariatric surgery in a patient population with obesity, primary care physicians report significant barriers to confidently referring their own patients. Further, bariatric surgery is overlooked in a large group of patients with BMIs between 35 and 40 kg/m2. Educational strategies to address these barriers should target rates of specific surgical complications and weight loss outcomes.

A 1-day simulation-based boot camp for incoming general surgery residents improves confidence and technical skills.

BACKGROUND: For surgery residents, opportunities to systematically learn about surgical equipment are limited. Our facility holds a simulation-based boot camp for incoming, first-year general surgery residents. The aim of this study was to assess the effectiveness of this boot camp at increasing resident confidence and improving technical skills. METHODS: Boot camp for incoming surgery residents is held annually and provides hands-on simulation relating to endoscopy, laparoscopy, bronchoscopy, and abdominal access. Before the boot camp, participants completed a pretest, which includes self-confidence, experience, and a skills-assessment. Identical assessments of self-confidence and skills were completed after the boot camp as a posttest. Data was accrued from 2016 to 2018. RESULTS: A total of 26, first-year, general surgery residents participated in the boot camp. Most participants had never used an endoscopic simulator (61.5%), handled a colonoscope (57.7%), a gastroscope (80.8%), or gained operative access to the abdomen (76.9%). The assessments of self-confidence and skills demonstrated a mean increase in all 4 topics. All differentials demonstrated statistical significance (P <. 001). CONCLUSION: A 1-day, simulation-based boot camp for incoming surgery residents with a focus on endoscopy, laparoscopy, and abdominal access increases resident confidence as well as several basic aspects of technical skill.

Laparoscopic inguinal hernia repair after prostatectomy: Evaluating safety, efficacy, and efficiency.

BACKGROUND: For many surgeons, a prior prostatectomy is considered a contraindication to laparoscopic totally extraperitoneal hernia repair. This study aims to evaluate the safety, efficacy, and efficiency of totally extraperitoneal in these patients. METHODS: This is a review of a prospectively collected hernia database evaluating patients who underwent totally extraperitoneal repair between October 2009 and March 2018. Patients with prior prostatectomy were matched to controls without prior prostatectomy. Secondary analysis compared the case group to patients who underwent open hernia repair. RESULTS: In the study, 1,751 patients underwent laparoscopic totally extraperitoneal repair. Thirty patients with a prior prostatectomy were matched to 90 controls. Operative duration was greater in the prostatectomy group (56 vs 36 minutes, P < .0001) and more peritoneal tears occurred (40% vs 12%, P = .002). Duration of stay, return to activity, complications, and rates of recurrence and chronic pain were equivalent. When compared with prior prostatectomy patients who underwent open hernia repair, the laparoscopic totally extraperitoneal group had equivalent rates of complications and outcomes with a faster return to activities of daily living (3 vs 7 days P = .007). CONCLUSION: Despite a more difficult dissection, laparoscopic totally extraperitoneal repair in patients with prior prostatectomy is safe, efficacious, and efficient. In addition, totally extraperitoneal offers similar outcomes to open repair with a quicker recovery in this patient population.

Patient-Centered Outcomes after Laparoscopic Paraesophageal Hernia Repair.

BACKGROUND: The aim of this study is to investigate patient-centered quality of life (QOL) outcomes in patients undergoing laparoscopic paraesophageal hernia repair. STUDY DESIGN: We prospectively followed patients who underwent laparoscopic paraesophageal hernia repair between 2009 and 2016. The QOL outcomes were measured using the 36-Item Short Form Health Survey, GERD Health Related Quality of Life, Reflux Symptom Index, and Dysphagia score surveys administered preoperatively and at 3 weeks, 6 months, 1 year, and 2 years postoperatively. Postoperative QOL outcomes were compared with preoperative baseline scores using paired t-tests. RESULTS: Of 314 total patients who underwent laparoscopic paraesophageal hernia repair, 188 with adequate follow-up were included in analysis. Mean age was 69.1 ± 11.8 years and 22.3% of studied subjects were male. Most of the cohort also underwent laparoscopic fundoplication (95.7%). Prevalent symptoms at initial presentation include heartburn (65.4%) and regurgitation (60.1%). Significant improvements between baseline and all postoperative time points were seen in Reflux Symptoms Index (3 weeks: p < 0.0001, 6 months: p = 0.005, 1 year: p = 0.0004, and 2 years: p = 0.002) and GERD Health Related Quality of Life scores (3 weeks: p < 0.0001, 6 months: p = 0.0019, 1 year: p < 0.0001, and 2 years: p = 0.0003). Dysphagia scores were worse at 3 weeks but lost significance at all other time points. The 36-Item Short Form Health Survey measures of Energy/Fatigue (p = 0.0099), Emotional Well-Being (p = 0.0393), Social Functioning (p = 0.0278), Pain (p = 0.0021), and Role Limitations Due to Physical Health (p = 0.0009) were significantly improved 2 years postoperatively. CONCLUSIONS: Laparoscopic paraesophageal hernia repair results in significantly improved QOL as measured by the 36-Item Short Form Health Survey at both short- and long-term intervals. Additionally, Reflux Symptom Index and GERD Health Related Quality of Life scores improved at all postoperative time points.

Gastroesophageal reflux disease in lung transplant patients with cystic fibrosis.

BACKGROUND: Gastroesophageal reflux disease (GERD) in lung transplant patients is being increasingly investigated because of its reported association with chronic rejection. However, information concerning the characteristics of GERD in cystic fibrosis (CF) patients is scarce. METHODS: We compared esophageal pH monitoring, manometry, gastric emptying studies, and barium swallow of 10 lung transplant patients with CF with those of 78 lung transplant patients with other end-stage pulmonary diseases. RESULTS: In lung transplant patients with CF, the prevalence of GERD was 90% (vs 54% controls, P = .04), of whom 70% had proximal reflux (vs 29% controls, P = .02). CONCLUSIONS: Lung transplant patients with CF have a significantly higher prevalence and proximal extent of GERD than do other lung transplant recipients. These data suggest that CF patients in particular should be routinely screened for GERD after transplantation to identify those who may benefit from antireflux surgery, especially given the risks of GERD-related aspiration and chronic allograft injury.

The prevalence and extent of gastroesophageal reflux disease correlates to the type of lung transplantation.

BACKGROUND: Evidence is increasingly convincing that lung transplantation is a risk factor of gastroesophageal reflux disease (GERD). However, it is still not known if the type of lung transplant (unilateral, bilateral, or retransplant) plays a role in the pathogenesis of GERD. STUDY DESIGN: The records of 61 lung transplant patients who underwent esophageal function tests between September 2008 and May 2010, were retrospectively reviewed. These patients were divided into 3 groups based on the type of lung transplant they received: unilateral (n=25); bilateral (n=30), and retransplant (n=6). Among these groups we compared: (1) the demographic characteristics (eg, sex, age, race, and body mass index); (2) the presence of Barrett esophagus, delayed gastric emptying, and hiatal hernia; and (3) the esophageal manometric and pH-metric profile. RESULTS: Distal and proximal reflux were more prevalent in patients with bilateral transplant or retransplant and less prevalent in patients after unilateral transplant, regardless of the cause of their lung disease. The prevalence of hiatal hernia, Barrett esophagus, and the manometric profile were similar in all groups of patients. CONCLUSIONS: Although our data show a discrepancy in prevalence of GERD in patients with different types of lung transplantation, we cannot determine the exact cause for these findings from this study. We speculate that the extent of dissection during the transplant places the patients at risk for GERD. On the basis of the results of this study, a higher level of suspicion of GERD should be held in patients after bilateral or retransplantation.

Assessing residents in surgical ethics: we do it a lot; we only know a little.

BACKGROUND: PGY-1 year of surgical residency brings together many persons of disparate experiences and educational backgrounds, including their exposure to ethics. We hypothesized that surgical PGY-1s would have a similar exposure to ethical scenarios but lack the confidence in practice and understanding of ethical principles compared with more senior residents. MATERIALS AND METHODS: Surgical residents were invited to resident-initiated surgical ethics workshops utilizing a standardized text. Here a survey and multiple choice tests were administered to participants. The survey determined prior exposure to ethics curricula, the frequency of exposure to various ethics topics, and their comfort with these scenarios. A multiple choice test then quantified the knowledge base of participating residents. The results were collected and compared between surgical PGY-1s and more senior residents. RESULTS: Eighteen PGY-1s and 12 senior residents completed this curriculum. Resident exposure to ethical concepts was common. Resident confidence in these topics was ranked moderate or higher for both groups. Despite frequent clinical exposure and strong confidence in their skills of addressing these topics, performance on the test was poor, with an average score of 59% for PGY-1s and 47% for more senior residents (P=0.03). CONCLUSIONS: Despite clinical exposure to and confidence in their management of ethical topics, their knowledge base was poor and worse for more senior residents. Given the overall interest in a formal ethics curriculum and the knowledge deficit demonstrated, educational intervention and professional ethics support should be provided for surgical residents even with the current educational time constraints.

Comparison of resident self-assessments with trained faculty and standardized patient assessments of clinical and technical skills in a structured educational module.

BACKGROUND: This study assessed the reliability of surgical resident self-assessment in comparison with faculty and standardized patient (SP) assessments during a structured educational module focused on perioperative management of a simulated adverse event. METHODS: Seven general surgery residents participated in this module. Residents were assessed during videotaped preoperative and postoperative SP encounters and when dissecting a tumor off of a standardized inanimate vena cava model in a simulated operating room. RESULTS: Preoperative and postoperative assessments by SPs correlated significantly (P < .05) with faculty assessments (r = .75 and r = .79, respectively), but not resident self-assessments. Coefficient alpha was greater than .70 for all assessments except resident preoperative self-assessments. CONCLUSIONS: Faculty and SP assessments can provide reliable data useful for formative feedback. Although resident self-assessment may be useful for the formative assessment of technical skills, results suggest that in the absence of training, residents are not reliable self-assessors of preoperative and postoperative interactions with SPs.

Causes of high mortality in colorectal surgery: a review of episodes of care in Veterans Affairs hospitals.

BACKGROUND: The episode of care for colorectal surgery in 8 outlier Veterans Affairs Hospitals with high mortality and the volume outcome relationship in 118 Hospitals are examined. METHODS: A total of 103 deaths were reviewed. Mean age was 74 with 63% of the patients undergoing emergency surgery; 54% of the patients had malignant disease and 21% had metastatic disease. RESULTS: Nineteen percent of the patients had a delay in diagnosis, 22% had delay in surgery and 14% should have received a different surgery usually less radical. In addition, system related issues were identified in 19% of the cases and practitioner related issues in 20% of the cases. The Spearman rank correlation between colorectal surgery volume and unadjusted mortality was 0.114 (P = 0.22). CONCLUSION: Colorectal surgery death is prevalent in elderly patients undergoing emergency surgery for malignancy or metastatic disease and is not related to hospital volume. Timely diagnosis, less radical surgery while optimizing system based pathways might improve outcome.

Preoperative evaluation: pulmonary, cardiac, renal dysfunction and comorbidities.

This article reviews evidence supporting the exercise of risk assessment and demonstrates how it assists in determining which patients should undergo a planned invasive procedure. The article focuses on the preoperative functional assessment of three major organ systems--cardiac, pulmonary, and renal--and reviews guide-lines for determining which patients need additional testing of organ system function. The article also discusses how to improve the condition of selected patients so that the surgeon can achieve the best possible result and outcome.

Management of adverse surgical events: a structured education module for residents.

BACKGROUND: This pilot project involved the development of a structured, experiential, educational module using a bench model technical skills simulation and standardized patients. It integrated teaching and assessment of clinical, technical, and interpersonal skills, as well as professionalism within the context of an adverse surgical event. METHODS: General surgery residents (postgraduate year [PGY] 2, 3) were asked to participate in the pre-, intra-, and postoperative management of a patient with a retroperitoneal sarcoma. Residents' performances during the module were assessed by standardized patients and faculty, and residents were provided feedback during debriefing sessions. RESULTS: Resident performance during the module was appropriate for the level of training. Residents found this module to be a realistic, challenging, and beneficial learning experience. CONCLUSIONS: Novel educational modules such as this one may serve as a useful addition to resident education in surgery residency programs, particularly in addressing patient safety and the core competencies. Reliability of the model may be enhanced by modifications of the module.

Exacerbation of acute pancreatitis by combined cholinergic stimulation and duct obstruction.

BACKGROUND: The role of cholinergic pathways in the pathogenesis of bile-pancreatic duct ligation (BPDL)-induced acute pancreatitis in rats remains controversial. We hypothesized that cholinergic stimulation exacerbates acute pancreatic inflammation in the presence of duct obstruction. METHODS: We studied 34 rats divided into 5 groups as follows: (1) sham operation; (2) BPDL; (3) BPDL with duodenal bile-pancreatic juice (BPJ) replacement fresh from a donor rat; (4) BPDL with BPJ replacement as in 3 above, and carbachol (CCh) 5 ug/h subcutaneously; or (5) CCh 5 ug/h subcutaneously only. Rats were killed after 6 hours. RESULTS: The P value was less than .05 by analysis of variance. Pancreatic morphologic changes and zymogen fraction hyperamylasemia seen with duct ligation (2 vs. 1) were ameliorated significantly by duodenal BPJ replacement (3 vs. 2), but not when exogenous CCh was administered (4 vs. 3), whereas CCh alone showed no significant changes compared with sham (5 vs. 1). CONCLUSIONS: Cholinergic stimulation and duct obstruction synergistically amplify acinar hyperstimulation and exacerbate acute pancreatitis.

Restoration of normal distensive characteristics of the esophagogastric junction after fundoplication.

OBJECTIVE: To study the mechanical characteristics of the esophagogastric junction (EGJ) of postfundoplication patients and compare them with previously reported data on normal subjects and GERD patients. METHODS: Eight normal subjects, 9 GERD patients, and 8 fundoplication patients were studied with concurrent manometry, fluoroscopy, and stepwise controlled barostat distention of the EGJ. The minimal barostat pressure required to open the EGJ during the interswallow period was determined. Thereafter, barium swallows were imaged in 5-mm Hg increments of intrabag pressure. EGJ diameter and length were measured at each pressure during deglutitive relaxation. RESULTS: EGJ opening diameter during deglutitive relaxation was on average 0.5 cm greater in GERD patients compared with normal subjects and fundoplication patients (P < 0.05). EGJ opening pressure and opening diameter were comparable between normal subjects and fundoplication patients; however, the EGJ length was 32% longer in fundoplication patients. CONCLUSIONS: Fundoplication restores distensibility of the EGJ to a level similar to normal subjects. Since trans-EGJ flow is related to EGJ length and EGJ diameter, these findings suggest that retrograde flow through the EGJ would be decreased by both a reduction in diameter and an increase in length of the EGJ.

The mechanical basis of impaired esophageal emptying postfundoplication.

Fundoplication (FP) efficacy is a trade-off between protection against reflux and postoperative dysphagia from the surgically altered mechanical balance within the esophagogastric segment. The purpose of the study was to contrast quantitatively the mechanical balance between normal and post-FP esophageal emptying. Physiological data were combined with mathematical models based on the laws of mechanics. Seven normal controls (NC) and seven post-FP patients underwent concurrent manometry and fluoroscopy. Temporal changes in geometry of the distal bolus cavity and hiatal canal, and cavity-driving pressure were quantified during emptying. Mathematical models were developed to couple cavity pressure to hiatal geometry and esophageal emptying and to determine cavity muscle tone. We found that the average length of the hiatal canal post-FP was twice that of NC; reduction of hiatal radius was not significant. All esophageal emptying events post-FP were incomplete (51% retention); there was no significant difference in the period of emptying between NC and post-FP, and average emptying rates were 40% lower post-FP. The model predicted three distinct phases during esophageal emptying: hiatal opening (phase I), a quasi-steady period (phase II), and final emptying (phase III). A rapid increase in muscle tone and driving pressure forced normal hiatal opening. Post-FP there was a severe impairment of cavity muscle tone causing deficient hiatal opening and flow and bolus retention. We conclude that impaired esophageal emptying post-FP follows from the inability of distal esophageal muscle to generate necessary tone rapidly. Immobilization of the intrinsic sphincter by the surgical procedure may contribute to this deficiency, impaired emptying, and possibly, dysphagia.

One hundred consecutive laparoscopic ventral hernia repairs.

BACKGROUND: Laparoscopic ventral hernia repair is becoming a promising alternative with many potential advantages, but this procedure is still under study. Our objective was to evaluate the efficacy of the laparoscopic approach to ventral hernia repair. METHODS: One hundred consecutive laparoscopic ventral hernia repairs between April 2000 and February 2003 were prospectively entered into a database and reviewed. RESULTS: Ninety-seven ventral hernia repairs were completed laparoscopically. The mean time in the operating room was 128 minutes (range 37 to 255). The average length of stay was 2 days (range 0 to 9). The mortality rate was 0%. A total of 23% of patients experienced postoperative complications. Over a mean follow-up period of 3 months (range 0 to 26), 6% (6 of 97) of patients experienced recurrences. CONCLUSIONS: Laparoscopic ventral hernia repair can be safely performed with a low conversion rate and acceptable recurrence rate, operative time, length of stay, and morbidity. Securing the mesh with full-thickness abdominal wall sutures in at least 4 quadrants remains a key factor in preventing early recurrence.

Mechanism of acute pancreatitis exacerbation by enteral bile-pancreatic juice exclusion.

Using an original model, the donor rat model, we previously showed that bile-pancreatic juice exclusion from gut exacerbates ligation-induced acute pancreatitis. Here, we examine the mechanism by which bile-pancreatic juice exclusion from gut exacerbates acute pancreatitis. In the first part of the study we test the hypothesis that Na taurocholate and trypsin are components of bile-pancreatic juice that exacerbate acute pancreatitis when excluded. Our experiments show that combined replacement of Na taurocholate and trypsin ameliorates acute pancreatitis. In the second part of the study we test the hypothesis that bile-pancreatic juice exclusion from gut exacerbates acute pancreatitis via combined CCK-A and cholinergic receptor pathways. Our experiments show that combined CCK-A and cholinergic receptor blockade significantly ameliorates acute pancreatitis while blockade of either receptor alone does not. We conclude that bile-pancreatic juice exclusion-induced exacerbation of ligation-induced acute pancreatitis involves a neurohormonal duodenal response to exclusion of trypsin and Na taurocholate resulting in acinar cell hyperstimulation via combined CCK-A and cholinergic receptor-mediated pathways.

Achalasia treatment: improved outcome of laparoscopic myotomy with operative manometry.

HYPOTHESIS: Operative manometry detects residual esophagogastric junction (EGJ) high pressure, ensuring complete myotomy. DESIGN: Consecutive patients undergoing laparoscopic myotomy. SETTING: Tertiary care academic medical center. PATIENTS: From 1997 to 2003, 139 patients with achalasia underwent laparoscopic myotomy. INTERVENTIONS: We assessed myotomy completeness by operative endoscopy and performed operative manometry to measure pressure across the EGJ myotomy. Residual high pressure was isolated and intact muscle divided. MAIN OUTCOME MEASURES: Esophageal manometry, quality of life, and dysphagia severity score. RESULTS: Median lower esophageal sphincter pressure was 27 mm Hg preoperatively; 10 patients had sigmoid esophagus and 57 had previous dilation and/or toxin injection. There were 136 laparoscopic myotomies and 3 conversions to open procedures (2%). Operative endoscopy was performed in all patients. Operative manometry, completed in 132 patients (95%), identified residual EGJ high pressure leading to myotomy revision in 45 patients (31 in the first 70 treated). Small perforations occurred in 19 patients, associated with previous dilation and/or toxin injection in 12 patients. One-month follow-up was available in 136 patients (98%); 126 patients had minimal symptoms (93%), whereas 1 had recurrent EGJ high pressure, 5 esophagitis, 3 sigmoid esophagus, and 1 paraesophageal hernia. In 60 patients with complete 1-year follow-up, quality of life and dysphagia improved (P <.05); mean lower esophageal sphincter pressure decreased to 7.6 mm Hg (P <.05). CONCLUSIONS: Operative manometry identifies residual EGJ high pressure and reduces the incidence of incomplete myotomy. Laparoscopic myotomy improves quality of life and dysphagia symptoms and may be the treatment of choice in most patients with achalasia.