by H. David Reines, MD
Dr. Reines is Vice Chairman, Department of Surgery, Inova Fairfax Hospital; Professor of Surgery, Virginia Commonwealth University, Virginia.
Ask medical students how much time their curriculum spends on pheochromocytoma and they will tell you 2 to 10 hours. Ask how long they spend on obesity and it may be two hours in physiology or biochemistry. Then ask medical students which disease they will see in their practice as a family practitioner, pediatrician, internist, psychiatrist, or surgeon, and they will admit obesity. Similarly, the average surgical resident is questioned more on Multiple Endocrine Neoplasia (MEN 2) on the American Board of Surgery In-service Examination (ABSITE) than on the surgical treatment of morbid obesity.
Medical School Curriculum
There is little data on what, how, or how much to teach about America’s most obvious health problem. A study of students demonstrated that those who were exposed to a bariatric surgical service significantly improved their obesity knowledge base. Second- and third-year students were given a 10-item questionnaire to assess knowledge of areas of obesity that included etiology, diagnosis, comorbidities, management, and treatment. Indications for surgery were also included. The correct response rate was 72 percent for second years and 82 percent for third years. Students who rotated on bariatric surgery scored significantly higher (90+2 vs. 79+2), but this experience may be impractical at many schools. Students need to be exposed to the problems of obesity and its comorbidities as a block in their curriculum so that the residents of tomorrow will have a base for understanding this major threat to the wellbeing of Americans. It is difficult to place obesity into the classical curriculum, which is discipline or body system oriented. In Israel, a 10-hour nutritional workshop was added to the clinical weeks of second-year students. The course was well received and case-based curricula added significantly to the students’ knowledge base. If the medical schools won’t or can’t accommodate making obesity a key part of the curriculum, then surgeons will have to assume some of this role during the third-year clerkship. Pediatrics, internal medicine, family practice, and psychiatry should also incorporate obesity-specific lectures and reading into their clerkships. In Europe, the problem of medical education on obesity is so minimally addressed to the point where some British medical schools have called for a European “action plan for obesity education.”
Areas of medicine where obesity is a major problem include all subspecialties. A recent study of internal medical residents found that obese patients (BMI>30Kg/m2) were identified only 30.9 percent of the time by medical residents, and only 24 percent had treatment recommended. Another study of internal medicine residents found that 60 percent did not know the minimum BMI for diagnosing obesity, and 31 percent felt treatment was futile. Pediatric residents were no better, with knowledge and attitudinal questionnaires demonstrating their ability to prevent and manage obesity was below expectations. Even basics, such as charting BMI, needed additional training programs. The Cochrane Database system examined the ability to improve education in the management of obesity for health professionals and found that we need to identify cost-effective strategies for the management of obesity. Interestingly, none of the papers reviewed for this review involved the use of bariatric surgery as a management tool.
General Surgical Resident Training
General surgery training is undergoing significant changes in curriculum, content, and procedures. A commission composed of the American College of Surgeons (ACS), American Board of Surgery (ABS), Residency Review Committee (RRC), and Association of Program Directors in Surgery (APDS) is working on a new standard curriculum for general surgery training. “Fast track” for vascular, cardiac, and plastic surgery is changing programs to three years of general surgical base followed by three years of specialty training. All of this is accompanied by a move to more minimally invasive surgery.
To meet the future needs of the general surgeon, we need to train surgeons to care and operate in the fastest growing area of surgery—bariatric (or metabolic as proposed by the ASMBS). The general surgeon of the future will have to understand the needs of bariatric patients and their preoperative, operative, and postoperative care. With the projection that over 140,000 bariatric procedures were performed last year, bariatrics becomes the fastest growing area in general surgery. This compares to less than 20,000 bariatric procedures in 1988 and 30,000 in 1999. To put that in perspective, in 1994 there were 689,000 groin hernias, while in 2004 there were 427,000 coronary artery bypass grafts (CABG) performed.10 Bariatrics is now in the top five of inpatient general surgical procedures.
All residents need to receive training in the basics of bariatric surgery, if only because there will not necessarily be a bariatric surgeon in the emergency room (ER) when a patient arrives two years out from surgery and has a Peterson’s hernia. What will the surgeon do with a ruptured spleen or a perforated gastric pouch if there is not a bariatric trained surgeon available? Bariatric medicine has to be part of the core curriculum. Whether or not a general surgery resident needs to be able to independently perform an entire gastric bypass for obesity is less important as we develop Centers of Excellence for obesity surgery, with individuals who spend one or two years understanding the entire approach to the morbidly obese patient. Every resident, however, will need to know what the possibilities are, how to care for the patient, what the metabolic preoperative and postoperative problems are, and most of all how to approach a bariatric patient who comes in for a problem related to surgery when no bariatric surgeon is around to give advice.
A true general surgeon will need to be involved in bariatric surgery just as he or she needs to be involved in other abdominal or breast surgery. If we are thinking of training surgeons to be emergency surgeons (a combination of critical care, trauma, and emergency surgery) we need to train them to be aware of and familiar with the concepts of bariatric surgery. It is wonderful that residents can perform a Whipple resection during their residency, and all should be exposed to this procedure; however, the reality is that few surgeons will be performing the Whipple in their private practice. Bariatric surgery, however, is somewhat different, as many more bariatric procedures are performed in the US than Whipples. According to Lillemoe, the mean number of gastric bypasses performed by senior residents in 2005 was 11.3 versus 4.0 Whipples and 8.5 parathyroids.
In a study examining the role of the surgical resident in gastric bypass surgery, Rovito, et al., reviewed 200 laparoscopic Roux-en-Y gastric bypasses (RYGB) in which surgical residents were either first assistant or performed the majority of the procedure. Residents were all Post Graduate Year 5 (PGY 5—chief residents) and originally began as first assistants. Residents rotated on the service for four months at a time. After first assisting on 8 to 10 cases, they were given increasing responsibility for the procedure. Breaking the procedure down into three components, the residents advanced in their ability to perform the entire procedure. The three components are transecting the stomach to create the gastric pouch, creating the jejunojejunostomy, and creating the gastrojejunostomy. The incidence of complications was comparable with other reported series, Residents averaged 170 minutes, which was not statistically longer than the attending. Surgical chief residents averaged 12 to 30 procedures as the primary surgeon. This study emphasizes that surgical residents can be trained to perform laparoscopic gastric bypass and learn procedures, which will serve them well in all areas of abdominal surgery.
Surgical training should incorporate both didactic and operative experience with bariatric procedures. Basic knowledge of obesity and its complications should be taught in the early years of residency, while the role of bariatric surgery in the control of the major comorbidities, including obstructive sleep apnea, adult onset diabetes, hypertension, stress incontinence, and gastroesophageal reflux disease (GERD), should be incorporated into the curriculum of all senior residents.
Indications for surgery and anatomical complications, such as internal hernias, leaks, cholelithiasis, and band erosion, need to be taught to all surgical residents. A study to asses surgical trainees’ attitudes and knowledge of surgery for morbid obesity revealed that 70 percent of applicants to a surgery program would want to perform bariatric surgery as part of their training. Overall, applicants answered correctly on 74 percent of the knowledge questions proposed, with only 18 percent understanding the impact of bariatric surgery on diabetes and 76 percent understanding the definition of morbid obesity.
Role of Minimally Invasive Surgery
One reason for the rapid rise in surgical therapy for obesity has been the acceptance of the use of minimally invasive techniques and a new generation of surgeons trained and interested in these techniques. Open gastric bypass and standard vertical banded gastroplasty have been practiced by bariatric surgeons for over 25 years and have been a major source for teaching gastric surgery to surgical learners. The number of these procedures performed was relatively stable for many years. A series of events led by improvements in laparoscopic surgery, the introduction of the laparoscopic banding procedure, and the publicity arising from bariatric procedures among celebrities have resulted in a marked increase in bariatric operations. The movement was advanced by the American Society of Bariatric Surgeons (ASBP) and Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and has created a demand for more well-trained bariatric surgeons. Consequently there has been a deluge of fellowships in the US to teach advanced minimally invasive techniques.
There are presently 130 programs enrolled in the National Resident Matching Program (NRMP) offering fellowships recognized as minimally invasive surgery (MIS) and gastrointestinal (GI) surgical training programs. Of these, five are purely bariatric and six are advertised as MIS/GI and bariatric. Although not recognized by the American Council for Graduate Medical Education (ACGME) as a specialty, they are coming under some regulation, are listed under the fellowship website www.nrmp.org/fellow/match, and are matched through a match system. These fellowships vary widely in experience and procedures, but one unifying factor is that almost all use advanced laparoscopic techniques. There is some data that the establishment of a bariatric surgery fellowship can shorten operative time for both open and laparoscopic surgery, further justifying a concentrated bariatric experience.
In 1988, 100 percent of bariatric procedures were performed open with an incision that varied from 6 to 10 inches and were placed either from xiphoid to umbilicus or in the left upper quadrant (LUQ). In 1994, the first fully laparoscopic bypasses were reported. By 1998, perhaps 10 percent of bariatric procedures were performed laparoscopically. It is estimated that in 2007, over 80 percent of procedures performed by fellows are laparoscopic. Originally revisions were felt to need open approach; however, as many primary procedures are being performed laparoscopically, even revisions are also being performed minimally invasively.
How does the “sea change” with a new approach affect results? Since the procedures are open or laparoscopic, one would expect the long-term results of gastric bypass to be similar, regardless of the approach used. A comparison study authored by Jones, et al., collected data from 16 experienced open bariatric surgeons who, with a combined total of 25,759 cases, pooled their data and compared their results to the data available for laparoscopic gastric bypass in the literature. The incisional hernia rate was 6.4 percent using a standard midline incisions, but was only 0.3 percent with a left upper quadrant incision. Mortality was 0.25 percent and leaks 0.4 percent. Average length of stay was 3.4, and cost/case in the operating room (OR) was significantly lower than the laparoscopic techniques.
The complication rate from incisional hernia and wound problems should be significantly less with laparoscopic techniques, but in several studies the leak rate was higher laparoscopically[19,20] and the internal hernia rate was higher as well. The reoperation rate for leak and the mortality rates are similar for both techniques. What will happen if the laparoscopically trained fellow never has to do a “dye test” for leak during his or her fellowship? Will they know how to fix a staple line disruption open? It appears that the conversion rate is less than five percent, meaning the average fellow doing 100 cases will only perform five open cases. Will fellows feel so uncomfortable with open procedures that they will spend hours trying to fix a laparoscopic problem, when a skin incision and an open approach would be faster and “curative?”
How many cases should a fellow perform to be considered competent or even an expert? The learning curve quoted by Oliak and Schauer[19,21,2] can be 75 to 100. On the other hand, Schwartz and Drew, experienced open surgeons, felt the number of cases was much lower if you had both laparoscopic skills and open bariatric experience.
The ASMBS abandoned the preceptorship program and established “guidelines for granting privileges in bariatric surgery.” It recommends that to obtain open bariatric privileges, the surgeon document “an operative experience of 15 open bariatric procedures.” Surgeons who perform “primarily laparoscopic bariatric surgery may obtain open privileges after documentation of 50 laparoscopic cases and at least 10 open cases supervised by an experienced bariatric surgeon.” It is possible but not likely that this can be accomplished in the average bariatric program, since the average minimally invasive bariatric cases performed per fellow was 95 (range 5–121). Are we training a new group of surgeons to feel more capable of using minimally invasive techniques than open, who will shy away from opening the patient either from expertise or hubris? Recently a laparoscopic surgeon attempted a feeding jejunostomy in a cancer patient who didn’t want an incision, and it took five hours! The total time in personnel, OR time, and equipment was substantial, but the patient did not get her big incision.
Since we cannot just open patients to train residents, we should be concerned that we are creating a generation who may not feel comfortable with a knife and will need to ask for help when they can’t perform a case minimally invasively.
We need to educate all medical professionals on the only proven treatment for morbid obesity, and the future of metabolic surgery. We need to train medical students, residents, and fellows about surgery for obesity, and we need to teach them in the classroom, office, and operating room. The surgical resident of today needs to be able to perform bariatric procedures. As we teach them laparoscopic techniques—be it a band, a sleeve resection, or a gastric bypass—we also need to wonder that when we, the baby boomers, need surgery in the future, will the surgeon working the scope have enough experience to open us if necessary and fix our problem?
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Category: Educational Perspective