Use of targeted educational resources to improve robotic bariatric surgery training.

BACKGROUND: Evidence for how to best train surgical residents for robotic bariatric procedures is lacking. We developed targeted educational resources to promote progression on the robotic bariatric learning curve. This study aimed to characterize the effect of resources on resident participation in robotic bariatric procedures. METHODS: Performance metrics from the da Vinci Surgical System were retrospectively reviewed for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases involving general surgery trainees with a single robotic bariatric surgeon. Pictorial case guides and narrated operative videos were developed for these procedures and disseminated to trainees. Percent active control time (%ACT)-amount of trainee console time spent in active instrument manipulations over total active time from both consoles-was the primary outcome measure following dissemination. One-way ANOVA, Student's t-tests, and Pearson correlations were applied. RESULTS: From September 2020 to July 2021, 50 cases (54% SG, 46% RYGB) involving 14 unique trainees (PGY1-PGY5) were included. From November 2021 to May 2022 following dissemination, 29 cases (34% SG, 66% RYGB) involving 8 unique trainees were included. Mean %ACT significantly increased across most trainee groups following resource distribution: 21% versus 38% for PGY3s (p = 0.087), 32% versus 45% for PGY4s (p = 0.0009), and 38% versus 57% for PGY5s (p = 0.0015) and remained significant when stratified by case type. Progressive trainee %ACT was not associated with total active time for SG cases before or after intervention (pre r = - 0.0019, p = 0.9; post r = - 0.039, p = 0.9). It was moderately positively associated with total active time for RYGB cases before dissemination (r = 0.46, p = 0.027) but lost this association following intervention (r = 0.16, p = 0.5). CONCLUSION: Use of targeted educational resources promoted increases in trainee participation in robotic bariatric procedures with more time spent actively operating at the console. As educators continue to develop robotic training curricula, efforts should include high-quality resource development for other sub-specialty procedures. Future work will examine the impact of increased trainee participation on clinical and patient outcomes.

Endoscopic Management of Gastric Band Erosion: a Systematic Review and Meta-Analysis.

BACKGROUND: Gastric band erosion may be seen in up to 3% of patients. Endoscopic intervention has become increasingly utilized due to its minimally invasive nature. The purpose of this study was to perform a systematic review and meta-analysis to examine the role of endoscopic removal for eroded gastric bands. METHODS: Individualized search strategies were developed for PubMed, EMBASE, Web of Science, and Cochrane Library databases in accordance with PRISMA and MOOSE guidelines. Outcomes included technical success, clinical success, procedure duration, adverse events, and surgical conversion. Pooled proportions were analyzed using random effects models. Heterogeneity and publication bias was assessed with I2 statistics and funnel plot asymmetry using Egger and Begg tests. Meta-regression was also performed comparing outcomes by endoscopic tools. RESULTS: Ten studies (n=282 patients) were included in this meta-analysis. Mean age was 40.68±7.25 years with average duration of band placement of 38.49±19.88 months. Pre-operative BMI was 42.76±1.06 kg/m2 with BMI of 33.06±3.81 kg/m2 at time of band erosion treatment. Endoscopic removal was attempted in 240/282 (85.11%) of cases. Pooled technical and clinical success of the endoscopic therapy was 86.08% (95% CI: 79.42-90.83; I2=28.62%) and 85.34% (95% CI: 88.70-90.62; I2=38.56%), respectively. Mean procedure time for endoscopic removal was 46.47±11.52 min with an intra-operative adverse event rate of 4.15% (95% CI: 1.98-8.51; I2=0.00%). Post-procedure-associated adverse events occurred in 7.24% (CI: 4.46-11.55; I2=0.00%) of patients. Conversion to laparotomy/laparoscopy occurred in 10.54% (95% CI: 6.12-17.54) of cases. CONCLUSION: Endoscopic intervention is a highly effective and safe modality for the treatment of gastric band erosion.

Human serous cavity macrophages and dendritic cells possess counterparts in the mouse with a distinct distribution between species.

In mouse peritoneal and other serous cavities, the transcription factor GATA6 drives the identity of the major cavity resident population of macrophages, with a smaller subset of cavity-resident macrophages dependent on the transcription factor IRF4. Here we showed that GATA6+ macrophages in the human peritoneum were rare, regardless of age. Instead, more human peritoneal macrophages aligned with mouse CD206+ LYVE1+ cavity macrophages that represent a differentiation stage just preceding expression of GATA6. A low abundance of CD206+ macrophages was retained in C57BL/6J mice fed a high-fat diet and in wild-captured mice, suggesting that differences between serous cavity-resident macrophages in humans and mice were not environmental. IRF4-dependent mouse serous cavity macrophages aligned closely with human CD1c+CD14+CD64+ peritoneal cells, which, in turn, resembled human peritoneal CD1c+CD14-CD64- cDC2. Thus, major populations of serous cavity-resident mononuclear phagocytes in humans and mice shared common features, but the proportions of different macrophage differentiation stages greatly differ between the two species, and dendritic cell (DC2)-like cells were especially prominent in humans.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD).

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. METHODS: Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. CONCLUSION: Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

National Trends in Pediatric Metabolic and Bariatric Surgery: 2010-2017.

BACKGROUND: The childhood obesity epidemic has grown exponentially and is known to disproportionately affect minority groups. Successful treatment of this complex health issue requires a multidisciplinary approach including metabolic and bariatric surgery (MBS) for qualifying pediatric patients. This study examines current national trends in pediatric bariatric surgery from 2010 to 2017 using the National Inpatient Sample. METHODS: This study analyzed MBS among pediatric patients <19 years old using weighted discharge data from 2010 to 2017. The primary outcome was national procedure rates. Secondary analyses included procedure type, demographics, BMI, comorbidities, length of stay, and complication rates. RESULTS: From 2010 to 2017, annual bariatric procedure rates increased from 2.29 to 4.62 per 100 000 (P < .001). Laparoscopic sleeve gastrectomy outpaced Roux-en-Y gastric bypass and laparoscopic adjustable gastric band over time (0.31-3.99 per 100 000, P < .0001). The mean age was stable over time 18.10-17.96 (P = .78). The cohort was primarily female (76.5% to 75.4%), white (54.0% to 45.0%), and privately-insured (59.9% to 53.4%). Preoperative BMI increased from 2010 to 2017 (P < .001), whereas number of obesity-related comorbidities was stable (P > .05). Length of stay was <2 days (2.02-1.75, P = .04) and in-hospital complication rates were low (7.2% to 6.45%, P = .88). CONCLUSIONS: Pediatric MBS is underutilized nationally with disproportionately lower rates among minority groups. Despite incremental progress, further investigation into the racial and social determinants that limit access to pediatric weight loss surgery is critical.

An Analysis of Diversity Statements and Support of Special Interest Societies by General Surgery Residency Programs.

OBJECTIVE: The purpose of this study was to characterize the nondiscrimination and diversity, equity, and inclusion (DEI) statements found on the websites of general surgery residency programs, as well as to measure programmatic commitment to diversity through their involvement with special interest surgical societies (SISS). DESIGN: The authors evaluated the relationship between DEI statements and SISS participation, and performed a natural language processing analysis of general surgery residency DEI statements. SETTING: The residency program websites from 319 non-military general surgery residency programs within the United States were analyzed. PARTICIPANTS: This study evaluated the DEI statement and SISS participation in general surgery residency programs. RESULTS: Of the 319 general surgery residency websites reviewed, 127 (39.8%) featured an identifiable statement of nondiscrimination or commitment to diversity. Compared to programs without diversity statements, programs with statements were more likely to be involved with special interest surgical societies (53.5% vs 30.7%, p < 0.001). Natural language processing analysis revealed that the diversity statements of programs with SISS involvement had higher word counts (p = 0.001), higher clout scores (measure of confidence conveyed, p = 0.001), and higher positive tone scores (p = 0.006) compared with the statements of those without special interest society involvement. CONCLUSIONS: In the era of virtual interviewing, applicants are forced to rely heavily on surgery residency websites as their main source of information. Less than 40% of programs participating in the Match in 2022 feature diversity statements on their websites. Programs with some degree of involvement with special interest societies were more likely to have statements that score higher in confidence and positivity in natural language processing analysis, which may potentially reflect a more earnest commitment to diversity, equity, and inclusion. Residency programs should continue to improve the visibility of their DEI efforts to recruit a diverse resident class.

National Trends and Outcomes in Adolescents Undergoing Bariatric Surgery.

BACKGROUND: In the US, obesity continues to be a severe health issue now affecting adolescents. Bariatric surgery remains the most effective treatment for obesity, but use among adolescents remains low. The objective of this study was to identify current national trends in bariatric surgery among adolescents. STUDY DESIGN: Using the Nationwide Inpatient Sample database, adolescents aged 9 to 19 with a diagnosis of morbid obesity who underwent a laparoscopic gastric bypass (Roux-en-Y gastric bypass) or laparoscopic sleeve gastrectomy (SG) between 2015 and 2018 were identified. Demographics, comorbidities, and in-hospital complications were collected. National estimates were calculated. The trend of annual number of operations was determined by Kruskal-Wallis rank test. RESULTS: Between 2015 and 2018, 1,203 adolescents were identified, resulting in a nationwide estimate of 4,807 bariatric cases. The number of bariatric operations increased annually from 1,360 in 2015 to 1,740 operations in 2018 (p = 0.0771). The majority of patients were female (76%), 17 to 19 years old (84.1%), and White (47.9%). Most patients underwent SG (82.0%). Black and Hispanic patients comprised 40.2% of the cohort. Significant comorbidities included diabetes, dyslipidemia, nonalcoholic fatty liver disease, hypertension, and sleep apnea. The average length of stay decreased from 2.12 days to 1.64 days. There were no in-hospital mortalities, and complications were less than 1%. CONCLUSIONS: With the increasing prevalence of obesity among adolescents in the US, bariatric surgery increased over time but was performed less in patients younger than 16 years of age and racial minorities. Bariatric surgery among adolescents remains safe, with extremely low complication rates and zero in-hospital mortality.

Infection prevention plan to decrease surgical site infections in bariatric surgery patients.

BACKGROUND: Surgical site infections (SSI) are one of the most common complications of bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (QI) Program (MBSAQIP) allows accredited programs to develop processes for quality improvement based on data collection. The objective of this study was to decrease SSI rates in patients undergoing bariatric surgery at an accredited MBSAQIP center. METHODS: Using the MBSAQIP semiannual report, SSI rates were retrospectively reviewed. Baseline SSI rates were collected from 01/01/2014-12/31/2015. On 01/01/2016, the first infection prevention protocol (IPP-1) was created that included 4% chlorhexidine gluconate (CHG) showers, CHG wipes immediately prior to surgery, and routine cultures of SSIs. An updated IPP (IPP-2) was implemented on 09/01/2016, which discontinued routine surgical drain placement and broadened antibiotic coverage for penicillin allergic patients. RESULTS: During baseline data collection, SSI rates were 5.1%. After the implementation of IPP-1, SSI rates trended down to 2.5%. After implementation of IPP-2, SSI rates decreased significantly to 1.5%, a 66% relative risk reduction in SSIs from baseline. On multivariate regression analysis, the perioperative factors associated with an increased risk for SSIs included diabetes mellitus, intraoperative surgical drain placement, the number of hypertension medications prior to bariatric surgery, and an open approach. CONCLUSIONS: Our study demonstrates that the implementation of a specific protocol for reducing SSIs is safe and feasible in patients undergoing bariatric surgery. We also identified that the success of the IPP is likely centered on the elimination of routine drain placement during primary bariatric procedures.

10-year weight loss outcomes after Roux-en-Y gastric bypass and attendance at follow-up visits: a single-center study.

BACKGROUND: Long-term durability of weight loss is a prerequisite for a greater acceptance of bariatric surgery. OBJECTIVES: To examine long-term weight trajectory in patients undergoing Roux-en-Y gastric bypass (RYGB) and determine factors predicting long-term follow-up and weight outcomes. SETTING: University hospital. METHODS: A retrospective cohort of adults who underwent RYGB during 1997-2010 were identified and followed until 2017. Predictors for attendance at periodic follow-up visits, reduction in body mass index (BMI), and percent excess BMI lost were determined using multivariable logistic regression and linear mixed-effects models. The latter was used to predict long-term weight outcomes for a typical patient. RESULTS: The study included 1104 patients with a mean age of 45.5 (standard deviation [SD] 9.9) years and a preoperative BMI of 54.7 (SD 10.9) kg/m2. Follow-up data were available for 92.8% of the patients after 1 year, 50.0% after 5 years, and 35.2% after 10 years post-surgery. Black patients, compared with White patients, were less likely to attend follow-up visits. Attendance at follow-up visits at least every other year was not associated with larger weight loss, but higher preoperative BMI, being White (versus Black), and female sex were. Predicted BMI reduction for a typical patient, a 45-year-old White female with a preoperative BMI of 54.7 kg/m2 and private health insurance, undergoing laparoscopic RYGB in 2004, was 18.3 (standard error [SE] .36) kg/m2 at year 5 and 17.6 (SE .49) kg/m2 at year 10. CONCLUSION: RYGB results in clinically significant and durable weight loss. Attendance at periodic follow-up visits does not appear to be associated with long-term weight loss outcomes. Future work should focus on strategies to remove barriers to post-operative care.

Understanding the Current Role of Robotic-Assisted Bariatric Surgery.

BACKGROUND: The role of robotic surgery in bariatrics remains controversial. Patient selection for robotic surgery is not well-studied. The objective of this study was to identify factors associated with robotic surgery and its temporal trends. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database from 2015 to 2018 was used. Adult patients undergoing primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) using the laparoscopic or robotic approach were identified. Revisional, hybrid, or those with concomitant procedures were excluded. Logistic regression was conducted to identify factors associated with undergoing robotic-assisted surgery. RESULTS: Among 211,568 patients who underwent SG, 9.1% underwent a robotic SG; among 76,805 patients who underwent RYGB, 7.9% of patients underwent a robotic RYGB. During 2015-2018, robotics increased from 7.1 to 11.3% for SG and 7.4 to 8.6% for RYGB. After controlling for patient characteristics, there was still an increasing trend in the use of robotic surgery: SG (multivariable-adjusted odds ratio, aOR, 1.18; 95% confidence interval, CI, 1.17-1.20) and RYGB (aOR, 1.05; 95% CI, 1.03-1.08). For both robotic SG and RYGB, functional status and African American race were associated with undergoing robotic surgery, while races other than White or African American and Hispanic ethnicity were not. Pre-operative IVC filter was associated with robotic SG, while the presence of GERD, diabetes, and COPD were associated with robotic RYGB. CONCLUSIONS: Robotic bariatric surgery has increased over time. Our findings identified factors associated with the receipt of robotic surgery. Reasons for these factors require further investigation to better delineate indications for this technology.

Robotic-assisted surgery enhances the learning curve while maintaining quality outcomes in sleeve gastrectomy: a preliminary, multicenter study.

BACKGROUND: The frequency of robotic-assisted bariatric surgery has been on the rise. An increasing number of fellowship programs have adopted robotic surgery as part of the curriculum. Our aim was to compare technical efficiency of a surgeon during the first year of practice after completing an advanced minimally invasive fellowship with a mentor surgeon. METHODS: A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted sleeve gastrectomy between 2015 and 2019 at a tertiary-care bariatric center (mentor group) and between 2018 and 2019 at a semi-academic community-based bariatric program (mentee 1 group) and 2019-2020 at a tertiary-care academic center (mentee 2 group). RESULTS: 257 patients in the mentor group, 45 patients in the mentee 1 group, and 11 patients in the mentee 2 group were included. The mentee operative times during the first year in practice were significantly faster than the mentor's times in the first three (mentee 1 group) and two (mentee 2 group) years (P < 0.05) but remained significantly longer than the mentor's times in the last two (mentee 1 group) and one (mentee 2 group) years (P < 0.05). There was no significant difference in venothromboembolic events (P = 0.89) or readmission rates (P = 0.93). The mean length of stay was 1.8 ± 0.5 days, 1.3 ± 0.5 days, and 1.5 ± 0.5 days in the mentor, mentee 1, and mentee 2 groups, respectively (P < 0.0001). There were no reoperations, conversion to laparoscopy or open, no staple line leaks, strictures, or deaths in any group. CONCLUSIONS: This is one of the first series to show that the robotic platform can safely be taught and may translate into outcomes consistent with surgeons with more experience while mitigating the learning curve as early as the first year in practice. Long-term follow-up of mentees will be necessary to assess the evolution of fellowship training and outcomes.

Initial Experience with a Virtual Platform for Advanced Gastrointestinal Minimally Invasive Surgery Fellowship Interviews.

BACKGROUND: The COVID-19 pandemic travel restrictions triggered a rapid alteration in the interview process for fellowships this spring. We describe our initial experience with virtual interviews for Advanced Gastrointestinal (GI) Minimally Invasive Surgery Fellowships and assess the value and limitations via a post-interview applicant survey. STUDY DESIGN: Twenty candidates were interviewed via Zoom teleconferencing during March and April 2020 using combined group and breakout rooms. An anonymous post-interview Likert and free text survey was sent to candidates with questions regarding feasibility, appropriateness, and acceptability of this method. RESULTS: Seventeen of 20 candidates (85%) responded to the survey. The candidates rated ease of interaction with the program director, faculty surgeons, and the current fellow highly: 94%, 83%, and 89%, respectively. The majority (53%) stated the virtual interviews exceeded or met expectations. Only a minority, 12%, reported the virtual platform was short of expectations. Approximately 70% noted little to no impact of not being able to conduct these interviews in-person and not being able to physically see the program institution. Overall, 94% were satisfied with their experience, and only 6% were neutral, with no respondents reporting dissatisfaction. Finally, 76% would recommend a virtual interview in the future. Most negative open response comments were secondary to issues with software rather than the lack of the in-person traditional interviews. CONCLUSIONS: The use of a remote teleconferencing platform provides a favorable method for conducting fellowship interviews and results in a high degree of candidate satisfaction. Virtual interviews will likely be increasingly substituted for in-person interviews across the spectrum of medical training.

Nasal positive pressure with the SuperNO2VA™ device decreases sedation-related hypoxemia during pre-bariatric surgery EGD.

INTRODUCTION: Pre-operative esophagogastroduodenoscopy (EGD) is becoming routine practice in patients undergoing bariatric surgery. Many patients with morbid obesity have obstructive sleep apnea (OSA), which can worsen hypoxia during an EGD. In this study, we report our outcomes using the SuperNO2VA™ device, a sealed nasal positive airway pressure mask designed to deliver high-fraction inhaled oxygen and titratable positive pressure compared to conventional nasal cannula. METHODS: Between June 2016 and August 2017, we conducted a prospective observational study that included 56 consecutive patients who presented for EGD prior to bariatric surgery. Airway management was done using either the SuperNO2VA™ (N = 26) device or conventional nasal cannula (N = 30). Patient demographics, procedure details, and outcomes were compared between the two groups. RESULTS: The SuperNO2VA™ group had a lower median age compared to the control group (38.5 vs. 48.5 years, p = 0.04). These patients had a higher body mass index (BMI) (47.4 vs. 40.5, IQR, p < 0.0001), higher ASA class (p = 0.03), and were more likely to have OSA (53.9% vs. 26.7%, p = 0.04). Desaturation events were significantly lower in the SuperNO2VA™ group (11.5% vs. 46.7%, p = 0.004) and the median lowest oxygen saturation was higher in the SuperNO2VA™ group (100% vs. 90.5%, p < 0.0001). DISCUSSION: This is the first study to report on the use of the SuperNO2VA™ device in bariatric patients undergoing pre-operative screening EGD. The use of the SuperNO2VA™ device offers a clinical advantage compared to the current standard of care. Our data demonstrate that patients with higher BMI, higher ASA classification, and OSA were more likely to have the SuperNO2VA™ device used; yet, paradoxically, these patients were less likely to have issues with desaturation events. Use of this device can optimize care in this challenging patient population by minimizing the risks of hypoventilation.

Outcomes in Older Patients with Grade III Cholecystitis and Cholecystostomy Tube Placement: A Propensity Score Analysis.

BACKGROUND: The Tokyo Guidelines recommend initial cholecystostomy tube drainage, antibiotics, and delayed cholecystectomy in patients with grade III cholecystitis. STUDY DESIGN: We used Medicare data (1996 to 2010) to identify patients 66 years and older who were admitted with grade III acute cholecystitis. We evaluated adherence to the Tokyo Guidelines and compared mortality, readmission, and complication rates with and without cholecystostomy tube placement in a propensity-matched (1:3) cohort of patients with grade III cholecystitis. RESULTS: There were 8,818 patients admitted with grade III cholecystitis; 565 patients (6.4%) had a cholecystostomy tube placed. Cholecystostomy tube placement increased from 3.9% to 9.7% during the study period. Compared with 1,689 propensity-matched controls, patients with cholecystostomy tube placement had higher 30-day (hazard ratio [HR] = 1.26; 95% CI 1.05 to 1.50), 90-day (HR = 1.26; 95% CI 1.08 to 1.46), and 2-year mortality (HR = 1.19; 95% CI 1.04 to 1.36) and were less likely to undergo cholecystectomy in the 2 years after initial hospitalization (33.4% vs 64.4%; HR = 0.26; 95% CI 0.21 to 0.31). Readmissions were also higher at 30 days (HR = 2.93; 95% CI 2.12 to 4.05), 90 days (HR = 3.48; 95% CI 2.60 to 4.64), and 2 years (HR = 3.08; 95% CI 2.87 to 4.90). CONCLUSIONS: Since the introduction of the Tokyo Guidelines (2007), use of cholecystostomy tubes in patients with grade III cholecystitis has increased, but the majority of patients do not get cholecystostomy tube drainage as first-line therapy. Cholecystostomy tube placement was associated with lower rates of definitive treatment with cholecystectomy, higher mortality, and higher readmission rates. These data suggest a need for additional evaluation and refinement of the Tokyo Guidelines.

Relative impact of surgeon and hospital volume on operative mortality and complications following pancreatic resection in Medicare patients.

BACKGROUND: Surgeon and hospital volume are both known to affect outcomes for patients undergoing pancreatic resection. The objective was to evaluate the relative effects of surgeon and hospital volume on 30-d mortality and 30-d complications after pancreatic resection among older patients. MATERIALS AND METHODS: The study used Texas Medicare data (2000-2012), identifying high-volume surgeons as those performing ≥4 pancreatic resections/year, and high-volume hospitals as those performing ≥11 pancreatic resections/year, on Medicare patients. Three-level hierarchical logistic regression models were used to evaluate the relative effects of surgeon and hospital volumes on mortality and complications, after adjusting for case mix differences. RESULTS: There were 2453 pancreatic resections performed by 490 surgeons operating in 138 hospitals. Of the total, 4.5% of surgeons and 6.5% of hospitals were high volume. The overall 30-d mortality was 9.0%, and the 30-d complication rate was 40.6%. Overall, 8.9% of the variance in 30-d mortality was attributed to surgeon factors and 9.8% to hospital factors. For 30-d complications, 4.7% of the variance was attributed to surgeon factors and 1.2% to hospital factors. After adjusting for patient, surgeon, and hospital characteristics, high surgeon volume (odds ratio [OR] = 0.54, 95% confidence interval [CI], 0.33-0.87) and high hospital volume (OR = 0.52; 95% CI, 0.30-0.92) were associated with lower risk of mortality; high surgeon volume (OR = 0.71, 95% CI, 0.55-0.93) was also associated lower risk of 30-d complications. CONCLUSIONS: Both hospital and surgeon factors contributed significantly to the observed variance in mortality, but only surgeon factors impacted complications.

The role of extended criteria donors in liver transplantation for nonalcoholic steatohepatitis.

BACKGROUND: Nonalcoholic steatohepatitis is expected to become the leading indication for liver transplantation. Use of extended criteria donors (ECD) may help with donor allocation in these patients. The objective of this study was to determine the use of ECDs in patients with nonalcoholic steatohepatitis undergoing liver transplantation to stimulate a liver-specific predictive model for ECD use. METHODS: The United Network for Organ Sharing database was used to identify patients undergoing liver transplantation for nonalcoholic steatohepatitis (2002-2014). Cox hazards models were created using (1) United Network for Organ Sharing ECD criteria (based on kidney allocation), (2) individual donor characteristics (age, sex, race, cause of death, body mass index, cold ischemic time), and (3) the Kidney Donor Profile Index (KDPI) to examine the effect of ECDs on mortality and graft failure. RESULTS: A total of 4,387 patients underwent liver transplantation for nonalcoholic steatohepatitis; 1,359 (30.9%) patients received an ECD. Transplantation with ECD livers had comparable patient survival (hazard ratio [HR] 1.06, 95% confidence interval [CI] 0.91-1.23) between donor types but an increased risk of graft failure (HR 1.18, 95% CI 1.03-1.36) compared to standard donors. Individual characteristics did not affect patient survival or graft failure. A 10% increase in KDPI was associated with a 28% increase in patient mortality (HR 1.28, 95% CI 1.02-1.60) and 45% increase in graft failure (HR 1.45, 95% CI 1.18-1.80). CONCLUSION: Based on the current United Network for Organ Sharing definition, ECDs in nonalcoholic steatohepatitis were associated with similar overall survival but increased risk of graft failure. Given the shortage of organs, creation of an easily calculated, liver-specific model similar to the KDPI may help risk stratify patients and improve organ allocation.