Scott Gmora

Mastery in Bariatric Surgery: The Long-term Surgeon Learning Curve of Roux-en-y Gastric Bypass

Objective: To determine the effect of cumulative volume on all-cause morbidity and operative time. Background: Gastric bypass is an important public health procedure, but it is difficult to master with little data about how surgeon cumulative volume affects outcomes longitudinally. Methods: This was a longitudinal study of 29 surgeons during the first 6 years of performing bariatric surgery in a high-volume, regionalized center of excellence system. Cumulative volume was determined using date and time of the procedure. Cumulative volume was analyzed in blocks of 75 cases. The main outcome of interest was all-cause morbidity during the index admission and the secondary outcome was operative time. Results: Overall, 11,684 gastric bypasses were performed by 29 surgeons at 9 centers of excellence. The overall morbidity rate was 10.1% and short-term outcomes were related significantly to cumulative volume. Perioperative risk plateaued after approximately 500 cases and was lowest for surgeons who had completed more than 600 cases (odds ratio 0.53 95% confidence interval 0.26–0.96 P = 0.04) compared to the first 75 cases. Operative time also stabilized after approximately 500 cases, with an operative time 44.7 minutes faster than surgeons in their first 75 cases (95% confidence interval 37.0–52.4 min P < 0.001). Conclusions: The present study demonstrated the clear, substantial influence of surgeon cumulative volume on improved perioperative outcomes and operative time. This finding emphasizes role of the individual surgeon in perioperative outcomes and that the true learning curve needed to master a complex surgical procedure such as gastric bypass is longer than previously thought, in this case requiring approximately 500 cases to plateau.

Regional Variations in the Public Delivery of Bariatric Surgery: An Evaluation of the Center of Excellence Model.

Objective:We evaluated regional access to bariatric surgery within the high-volume, center of excellence (COE) model of Ontario, Canada. Background:In 2009, Ontario implemented Canadas first regionalized bariatric surgical care system based on a COE. Because of this, a small number of COEs service a large population and geographic area. Methods:This study identified all patients older than 18 years, who received bariatric surgery from April 2009 to March 2012. Morbid obesity-adjusted rates of surgery were then calculated for each neighborhood, and a cluster analysis was performed to determine aggregation of neighborhoods with significantly higher (hot spots) or lower (cold spots) rates of surgery. Ordinal logistic regression was used to identify independent predictors of neighborhood access. Results:The cluster analysis identified 49 cold spot neighborhoods, representing 1.7 million people. Forty of these neighborhoods lie within a relatively small area that contains 3 of the 4 COEs. In the multivariate analysis, for every 100 km from the nearest COE, neighborhoods were 0.88 times as likely to live in a hot spot [95% CI (confidence interval): 0.80–0.97; P = 0.012]. In addition, having a bariatric facility within the same administrative health region as the neighborhood made it almost twice as likely to be a hot spot, odds ratio = 1.75 (95% CI: 1.10–2.79; P = 0.018). Low neighborhood socioeconomic status was not associated with decreased delivery of care. Conclusions:This study identified an unequal delivery of bariatric surgery within Ontario. Both longer distances and not having a bariatric facility within the same health region had significant negative effects. Further research into patient attitudes and referral patterns is required to better characterize these disparities.

A comparison of 30-day versus 90-day proton pump inhibitor therapy in prevention of marginal ulcers after laparoscopic Roux-en-Y gastric bypass

BACKGROUND Marginal ulceration is one of the most common complications after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Proton pump inhibitors (PPIs) are commonly administered to decrease the incidence of marginal ulcer development. OBJECTIVE We examine the differential impact of employing a 30-day versus 90-day postoperative PPI regimen on the development of marginal ulceration after LRYGB. SETTING University hospital. METHODS A retrospective cohort design was used to study all patients undergoing LRYGB at a single, high-volume bariatric center in Hamilton, Ontario, Canada. Three years previously, the duration of postoperative PPI administration was increased at our center from 30 to 90 days. Diagnosis of marginal ulceration was confirmed by upper endoscopy in patients presenting with epigastric pain and a clinical history suggestive of marginal ulceration. A χ(2) test of independence was performed to examine incidence of marginal ulceration and PPI duration. RESULTS A total of 1016 patients underwent LRYGB at our center between January 2009 and January 2013. No differences in baseline characteristics were observed between groups. Of the 1016 patients followed, 614 received 30 days of PPI therapy and 402 received 90 days of PPI therapy. The incidence of marginal ulceration after LRYGB decreased significantly (P<.05) among patients receiving daily PPI for 90 days (n = 26, 6.5%) compared with those receiving PPI for 30 days (n = 76, 12.4%). CONCLUSION This study suggests a significant benefit to longer duration prophylactic PPI administration after gastric bypass surgery to minimize the risk of symptomatic marginal ulceration.

Geographic and socioeconomic factors affecting delivery of bariatric surgery across high‐ and low‐utilization healthcare systems

In countries with universal health coverage, the delivery of care should be driven by need. However, other factors, such as proximity to local facilities or neighbourhood socioeconomic status, may be more important. The objective of this study was to evaluate which geographic and socioeconomic factors affect the delivery of bariatric care in Canada.

Laparoscopic Hemorrhage: Do We Have to Open?

You’re dissecting Calot’s triangle during a routine elective cholecystectomy. Sure, the patient is rather large, but you’ve done this dissection hundreds of times before without breaking a sweat. This time, however, as you spread your Maryland dissector to clear some remaining tissue just medial to the cystic artery, the blood begins to spill at a shockingly rapid rate. You immediately feel a sick sensation in the pit of your gut.