Christopher J. Neylan

The Surgical Management of Obesity

In the United States, more than one-third of the population is obese. Currently, bariatric surgery is the best known treatment for obesity, and multiple meta-analyses have shown bariatric surgery to be more effective for treating obesity than diet and exercise or pharmacologic treatment. The modern era of bariatric surgery began in 2005, which is defined by a drastic increase in the use of laparoscopy. Bariatric surgery has the potential to improve obesity-related comorbidities, such as type 2 diabetes, cardiovascular disease, and sleep apnea. The effect of bariatric surgery on weight loss and comorbidities varies by the type of procedure.

Endoscopic treatments of obesity: a comprehensive review

BACKGROUND Obesity remains a significant problem in the United States. Bariatric surgery is the most effective treatment for obesity, but it is cost-prohibitive on both a national and individual scale. Access is also limited, and less than 1% of the eligible population receives bariatric surgery. Endoscopic therapies for obesity have emerged as an alternative to bariatric surgery, 2 of which have recently been approved by the U.S. Food and Drug Administration (FDA). This study provides a comprehensive overview of the endoscopic treatments of obesity and summarizes their outcomes. OBJECTIVES To provide clinicians with a comprehensive overview of the endoscopic treatments of obesity. SETTING University Hospital, United States. METHODS Multiple searches of PubMed were conducted using various keywords and MeSH terms. Backwards citation searching and hand-searching were also conducted to ensure completeness. RESULTS The current endoscopic treatments of obesity can be divided into 6 main categories: 1) space-occupying devices, 2) restrictive procedures, 3) bypass liners, 4) electrical stimulation, 5) aspiration therapy, and 6) other therapies. Intragastric balloons, a space-occupying device, are the best-studied of all the treatments. They show 30%-50% excess weight loss after device removal but lack significant long-term follow-up. CONCLUSIONS With the recent Food and Drug Administration approval of intragastric balloons, this treatment is likely to rise in popularity. Short-term outcomes appear promising but long-term results are unclear.

Ranibizumab Versus Mitomycin C in Primary Trabeculectomy – A Pilot Study

ABSTRACT Purpose: The current standard adjunctive agent used in primary trabeculectomy is mitomycin C (MMC), but it is associated with well known complications. The objective of this study is to test the feasibility of the anti-vascular endothelial growth factor (anti-VEGF) agent ranibizumab for adjunctive use instead of MMC (0.4 mg/ml). Materials and methods: A prospective, randomized open label study of 24 consecutive patients undergoing primary trabeculectomy at the Wills Eye Institute Glaucoma Service from March 2008 through February 2010 was conducted. Twenty-four eyes were included in the study and clinical outcomes were examined. Results: There were no significant differences in baseline demographic or clinical characteristics between the ranibizumab and MMC groups. Nine of the 12 ranibizumab patients completed the 1 year study. Three subjects required tube shunt surgery and were removed from the study. Eleven of 12 MMC patients completed the study (one underwent hip surgery and was lost to follow-up). Mean intra-ocular pressure (IOP) was significantly higher in the ranibizumab arm at 1 month (p = 0.002). Bleb extent was significantly less in the ranibizumab arm at 6 months (p = 0.006). Patients in the ranibizumab arm required more hypotensive medication at month 3 (p = 0.011). Conclusions: Although there was no IOP difference or difference in medication use between the two treatment groups at one year, more patients in the ranibizumab group required additional glaucoma surgery during the study period.

Medical School Surgical Boot Camps: A Systematic Review

PURPOSE Many medical schools have begun to offer surgical boot camps to senior medical students. The aim of the present study is to systematically review the literature and evidence surrounding medical school surgical boot camps to direct future research into the effectiveness of boot camps. METHODS A systematic review was conducted, searching MEDLINE, EMBASE, PsycINFO, CINAHL, and ERIC. The review was conducted according to the PICOTS structure, with an intervention of a surgical boot camp for senior medical students entering surgical residencies. RESULTS The search resulted in 5351 database hits, from which we identified 10 published studies that met the inclusion criteria. Two reviews were identified that met the PICOTS criteria but were excluded from data synthesis. Boot camps increase the confidence and competence of medical students entering their surgical internships. There is no objective assessment of the effect of boot camps on the clinical performance of interns. CONCLUSIONS Despite the success of medical school surgical boot camps, no objective data exist to show that boot camps translate into improved performance during internship.

Can Simulated Team Tasks be Used to Improve Nontechnical Skills in the Operating Room

OBJECTIVE The purpose of this study was to understand the effect of a team-based surgical skills intervention on the technical and nontechnical skills of surgery residents. DESIGN This was a prospective cohort study with pretesting or posttesting. We designed basic tasks for the assessment and learning of nontechnical skills in the operating room (OR). A total of 15 postgraduate year 1 residents performed an open gastrojejunostomy in a simulated OR setting (pretest), followed by training in the 3 team-based tasks designed to teach communication and teamwork, followed by performance of a gastrojejunostomy in the simulated OR (posttest). SETTING Tertiary care, university-based teaching institution. PARTICIPANTS A total of 15 general surgery residents at the intern level. RESULTS The mean nontechnical skills for surgeons (NOTSS) score improved postteam task training (10.04 ± 0.33 vs. 12.14 ± 1.33). There was a concomitant increase in the objective structured assessment of technical skills (OSATS) score (18.56 ± 0.86 vs. 22.86 ± 0.15, p = 0.006). The percentage increases in OSATS and NOTSS score for each resident was similar (19.49 ± 4.8 % for NOTSS vs. 21.22 ± 4.92 % for OSATS, p = 0.502). CONCLUSION Nontechnical skills positively correlate with the technical performance of a surgeon. Simple, easily designed tasks can be used to improve NOTSS in the OR. These team tasks and development of curricula based on them can be used to explicitly address one of the most important components of ACGME core competencies for surgical residents, namely interpersonal skills and communication.

In Situ Operating Room–Based Simulation: A Review

OBJECTIVE To systematically review the literature surrounding operating room-based in situ training in surgery. METHODS A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible. RESULTS The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics. CONCLUSIONS Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated.