"This ain't my first rodeo..."

I honestly have never been to a rodeo, and I paused when I thought of the title for this blog this week, as this saying is a little tired.  But I think I can make it work here....

From meco1.blogspot.com

Please read on.

I discovered another weight loss surgery article this week, entitled Surgical Skill and Complication Rates after Bariatric Surgery, from this week's NEJM.

The article was intriguing for a couple of reasons. It revealed an effective way to assess an independent factor for surgical complications, one that has heretofore been either overlooked or avoided, for it has been difficult to assess.  The implication of this lack of published data on this specific variable, that seemingly defies logic, has been that this factor is not truly a primary determinant to surgical outcomes. It has been easier to study related issues, such as perioperative care algorithms, but not the central issue on full display in this study.

The surgeon and his /her skills were on review, and there was a significant correlation with complication rates and the aptitude of their skills, as reviewed by a group of their peers.

In the study, 20 Bariatric surgeons in Michigan were involved in a statewide collaborative improvement program, and submitted a single representative video of one of their Gastric Bypass cases. A group of their peers reviewed the critical aspects of the recorded procedure (creation of gastric pouch,  gastro-jejunomostomy, and jejuno-jejunostomy). The blinded video was assessed in a number of established categories for an overall score rating surgeon skill.

The background for this study acknowledged a few important points. It is known that surgical skill, in any specialty can vary widely. Results of surgery, and specifically Bariatric surgery, can also vary significantly, in terms of weight loss results as well as complication rates. In many previous studies involving outcomes and complications, numerous other factors have been evaluated, mostly in the realm of perioperative care protocols.  Again, studying complications was the focus here, including such untoward effects as surgical site infection, wound dehiscence, intrabdominal abscess, anastamotic stricture, bowel obstruction, bleeding, respiratory failure, VTE, MI, cardiac arrest, and death, as well as unplanned reoperation, readmission, and ER visits.

And lastly, it is also widely understood that the skill level in performing Gastric Bypasses, as a common but technically demanding and complex procedure, would therefore likely demonstrate what they aimed to appraise - the suspected relationship between surgeon skill and complication rate.

So..... What did they find?

1.  Greater skill, as demonstrated by the peer video review process, did correlate positively with a lower complication rate, (along with less reoperations and readmissions) as well as with a shorter duration of operative procedure time.

2. Those surgeons with higher skill, and thus lower complication rates (etc. as above) had an important common bond. It wasn't related to years in Bariatric surgery practice, status in terms of completion of a fellowship in an advanced or laparoscopic bariatric fellowship, or current practice at a teaching or non teaching hospital. What was it?

The higher skill level was strongly related to surgical volume, as in the number of cases already performed.

3. On a personal note, the article specifically noted that the possible extent to which the First Assistant to the surgeon (that would be one of my job duties) could influence the ease of the procedure by the surgeon, and therefore complication rates, was not studied at this time*.

4. And finally, as researchers have a proclivity to do, the results of the study seemed to validate that the peer rating process of surgical skill itself, looks to be an effective strategy for assessing a surgeon's proficiency.

Good stuff overall, and an effective current and trustworthy resource for the argument that high volume centers are the standard for the most effective patient care in terms of a lower complication rate, and perhaps even can be extrapolated to results as well, but that was not covered here.

All of this kind of flies in the face the recent CMS proclamation that Medicare will no longer require that designation in order to approve bariatric surgery for one of their patients (see previous blog post, "One Bad Apple Could Spoil the Whole Bunch (Girl)"), but such is life...


*Note:  The surgical "team", inclusive of a well-trained OR Tech, Nurse,  First Assistant, as well as Anesthesia personnel,  PACU and Med-Surg Floor staff were studied in the past and deemed essential to good outcomes, as occurs in other surgical subspecialties such as CardioThoracic surgery.