Tyler W. Barreto

Evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients

BACKGROUND Both hiatal hernias (HH) and morbid obesity significantly contribute to gastroesophageal reflux disease, which increases the risk for esophagitis and esophageal cancer. Therefore, concomitant HH repair is recommended during bariatric surgery procedures. Unfortunately, recurrence of HH after repair is not uncommon and the optimal surgical technique has yet to be established. OBJECTIVE To evaluate the feasibility of recreating the phrenoesophageal ligaments by adding phrenoesophagopexy to HH repair during sleeve gastrectomy. SETTING Independent, university-affiliated teaching hospital. METHODS Retrospective chart review of all patients with a body mass index ≥35 kg/m2 who underwent a combined sleeve gastrectomy and HH repair between January 2010 and December 2014 by a single surgeon at a single institution. Demographic data and 30-day postoperative complications rates were obtained. RESULTS There were 106 patients evaluated. Mean age was 50.8 ± 12.5 years, mean body mass index was 45.8 ± 7.1 kg/m2, and 87% were female. Mean operative time was 112 ± 24.5 minutes, and mean length of stay was 1.9 ± .7 days. The 30-day complication rate was .94% (1 gastric sleeve leak) and there were no deaths. Six patients (5.7%) required emergency department evaluation, and 5 (4.7%) required readmission for abdominal pain (2), dysphagia/dehydration (1), esophagitis (1), or gastric sleeve leak (1), which required reoperation. CONCLUSION The addition of an interrupted phrenoesophagopexy for HH repair during sleeve gastrectomy appears to be a feasible technique with low 30-day morbidity and mortality rates. Long-term follow-up is needed to evaluate the efficacy in reducing HH recurrence rates.

Intention Versus Reality: Family Medicine Residency Graduates' Intention to Practice Obstetrics

Although 21% of new family medicine graduates in 2016 reported an intention to include obstetric delivery in their scope of practice, only 7% of family physicians currently do so. The reasons for this stark difference must be identified in order to address potential barriers leading to family medicine graduates ultimately not including obstetric delivery despite intent.

Re: The Numbers Quandary in Family Medicine Obstetrics

Re: The Numbers Quandary in Family Medicine Obstetrics (J Am Board Fam Med 2018;31:169.) To the Editor: Worth brings up some important points including outcomes and training. As described, there are several studies that demonstrate equivalent outcomes between family physicians and obstetricians. Worth voices concern about the paucity in outcomes literature based on various limitations. Of the 3 recent studies cited, 1 is in Canada, which, while there are clear health care differences, presumably the patients and procedures are not so different that we must exclude it. The other 2 articles cited had over 14,000 patients and found a significantly lower cesarean-section rate among patients delivered by family physicians with all other outcomes equivalent whether delivery was attended by a family physician or obstetrician. These studies support previous research documenting equivalent outcomes, and leave us wondering how many times does equivalency in outcomes need to be demonstrated. However, with recent changes in family medicine training requirements, we do agree that there is a need for new studies to assess how these changes may affect outcomes in obstetric care. Regarding training standards, family medicine is a broad field with many competing interests. Decades of work conducted by the family medicine community, Accreditation Council for Graduate Medical Education (ACGME), and Family Medicine Residency Review Committee (RRC) has been done to ensure competency is achieved in each of the Family Medicine domains of practice, including obstetrics. Despite the lowered ACGME obstetric requirements, more intensive training in obstetrics via electives, mentoring, or fellowship is available for physicians interested in increasing their obstetric experience. Our finding that 23% of recent graduates want to include obstetric deliveries is encouraging both for believers in the full spectrum of family medicine and for patients who are facing higher maternal and infant morbidity. A study of over 2.6 million births in California found that rural women who were able to deliver in a rural hospital had decreased rates of morbidity and mortality. However, rural hospitals continue to close labor and delivery units. If a local family physician provided obstetric care at a local hospital, women would not have to travel such distances and may see improvement in outcomes. We agree that all patients deserve nothing less than highly qualified, competent physicians. Our concern is not simply that the numbers of family physicians delivering babies is decreasing. Our concern is that at a time of national shortage of obstetric care, there are 2000 family physicians who intended to provide obstetric care after graduating and are being prevented by barriers that have nothing to do with their training or competence. We might improve maternal and infant morbidity if the family physicians who are interested and competent in obstetric care are able to provide that care. Tyler Barreto, MD, UT Health San Antonio, San Antonio, TX Aimee R. Eden, PhD, MPH, American Board of Family Medicine, Lexington, KY Andrew Bazemore, MD, MPH, Robert Graham Center, Washington, DC Lars E. Peterson, MD, PhD American Board of Family Medicine, Lexington, KY

Barriers Faced by Family Medicine Graduates Interested in Performing Obstetric Deliveries

Fewer family physicians are providing deliveries, which raises concern for access to obstetric care. We found that among recent family medicine graduates who would like to do deliveries, difficulty finding a position that supports including deliveries was a major barrier.

A matched cohort study of laparoscopic biliopancreatic diversion with duodenal switch and sleeve gastrectomy performed by one surgeon

SETTING Spectrum Blodgett and Mercy Health St. Marys hospitals in Grand Rapids, Michigan OBJECTIVE: To compare the 30-day outcomes of laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) to laparoscopic sleeve gastrectomy (SG). BACKGROUND Laparoscopic BPD/DS has been shown to be superior to SG in terms of excess weight loss. Despite this superiority, BPD/DS accounts for a small percentage of all metabolic surgeries due partly to the perception that BPD/DS has a higher complication rate than SG. METHODS Retrospective review of all patients who underwent BPD/DS or SG from January 2008 to August 2014 by 1 surgeon was completed. These patients were used to construct cohorts matched via propensity score matching and compared by surgical type. Data collected included patient demographic characteristics; hospital length of stay (LOS); and 30-day rates of leak, bleed, reoperation, readmission, and mortality. RESULTS Of the 741 patients who underwent BPD/DS or SG, 2 cohorts of 167 patients each were matched for age, sex, and BMI. LOS was longer in the BPD/DS cohort (2.5±.9 days versus 2.1±.7 days, P<.001). There were no significant differences between the groups in relation to 30-day postoperative rates of leak (.3% versus .6%, P>.99), bleed (0% versus .3%, P>.99), reoperation (1.2% versus .6%, P>.99), or readmission (3% versus 1.2%, P = .45). There were no mortalities. CONCLUSION After matching for age, sex, and BMI, BPD/DS found no significant differences from SG with regard to 30-day postoperative rates of leak, bleed, reoperation, readmission, or mortality.