Raising the Standard: The Joy and Privilege of a Surgical Career: An Overview of the American College of Surgeons Clinical Congress 2018

| December 1, 2018 | 0 Comments

by Dominick Gadaleta, MD, FACS, FASMBS, and Anthony T. Petrick, MD, FACS, FASMBS 

This column is dedicated to highlighting a broad range of quality issues in bariatric surgery.

Dr. Gadaleta is Associate Chair, Chief of General Surgery, MBS Director, North Shore University Hospital, Northwell Health, Manhasset, New York. Dr. Petrick is Quality Director, Geisinger Surgical Institute; Director of Bariatric and Foregut Surgery, Geisinger Health System, Danville, Pennsylvania.

Funding: No funding was provided for this article.

Disclosures: The authors reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2018;15(12): 8–9.

Abstract: The authors provide an overview of the American College of Surgeons Clinical Congress 2018, held in Boston, Massachusetts, October 21 to 25, 2018. The program reflected the theme of the meeting, “Joy and Privilege of a Surgical Career,” with education and training for surgeons to achieve the best outcomes in treating patients with obesity. Researchers from around the world presented the latest data on topics such as diabetes outcomes following bariatric surgery, the effect of surgical skill on outcomes for laparoscopic sleeve gastrectomy, and preoperative weight loss and its effect on surgical outcomes. The American College of Surgeons also recognized the 2018 Excellence in Research Award recipients during the meeting.

Keywords: Bariatric surgery, American College of Surgeons, obesity, weight loss, Roux-en-Y gastric bypass, sleeve gastrectomy

For the first time, the American College of Surgeons (ACS) held their Clinical Congress in Boston, Massachusetts. The 2018 Program Committee, headed by Henri R. Ford, MD, MHA, FACS, FAAP, FRCSEng (Hon), and the ACS Division of Education, led by Ajit K.Sachdeva, MD, FACS, FRCSC, developed an outstanding scientific program to address education and training needs for surgeons to achieve the best outcomes in these challenging times.

There were four separate scientific forums devoted to bariatric/foregut surgery, one video session, and one poster session. In the video-based education session, coordinated by Aurora Pryor, MD, FACS, and Garth Jacobsen, MD, FACS, videos covering diverse and complicated topics, such as reversal of Roux-en-Y gastric bypass (RYGB) for recalcitrant hypoglycemia, accidental thoracic esophageal perforation during laparoscopic sleeve gastrectomy (LSG), and magnetic-assisted liver retraction, were presented and discussed.

Nine posters were presented at Station 4, moderated by Shanu Kothari, MD, FACS, and Sheila Partridge, MD, FACS. The e-posters presented from centers around the world explored topics such as the effects of tobacco smoking on weight loss after LSG, preoperative weight loss as a predictor of percent excess weight loss after bariatric surgery, and taste perception after bariatric surgery. In the panel session, “Metabolic Surgery: Physiologic Mechanisms and Clinical Outcomes,” moderated by Ali Tavakkoli, MB, BS, FACS, and Jayleen Grams, MD, PhD, FACS, Anita Coucoulas, MD, MPH, FACS, from University of Pittsburgh (Pittsburgh, Pennsylvania) delivered an excellent review of the literature on diabetes outcomes following bariatric surgery. Randy Seeley, PhD, from University of Michigan (Ann Arbor, Michigan) discussed how bariatric surgery works, focusing on changes in the brain following surgery. Ali Tavakkoli, MD, from Brigham and Women’s Hospital (Boston, Massachusetts) discussed using science to improve surgery and Naji Abumrad, MD, from Vanderbilt University Medical Center (Nashville Tennesee) discussed using science to replace surgery.

Some of the highlights from Scientific Bariatric Forum I, moderated by Amir Ghaferi, MD, FACS and Jacob Greenberg, MD, MS, FACS, included a video-based study from the Michigan Bariatric Collaborative in evaluating the effect of surgical skill on outcomes for laparoscopic sleeve gastrectomy, presented by Oliver Varban, MD, FACS. Blinded videos of routine sleeve gastrectomy were submitted and reviewed in Objective Structured Assessment of Technical Skill (OSATS) format. The study compared their rated skill level to their patient overall outcomes. They found that skill rating did not affect 30-day overall complication rate. Fellowship training status and years in practice did not affect skill rating. When broken down, there was a lower rate of sleeve obstruction and bleeding in the higher-skilled group of surgeons. Higher volume surgeons tended to receive higher subjective skill scores. The future plan is to create an educational video platform to serve as a library resource.

A paper from the Medical College of Wisconsin on practice patterns for extended chemoprophylaxis following bariatric surgery in the United States used a national pharmacy database to determine postoperative utilization of extended venous thromboembolism (VTE) prophylaxis. Eleven percent of all bariatric patients had postoperative chemoprophylaxis prescribed, usually enoxaparin. Seventy percent of all postoperative VTE occurred within 30 days. Risk factors for VTE included male sex, increasing age, and presence of hypercoagulable disorder. Outpatient chemoprophylaxis prescribing varied from 0.5 percent for some programs, up to 37 percent from other programs. They concluded there is wide variability in extended chemoprophylaxis prescribing patterns across the country and there is a need for more data and consistent guidelines.

A paper from University of Miami questioned whether all post-discharge VTE events were captured in current quality metrics. They looked at a national readmission database and found that at one year, 40 percent of patients with postoperative VTE were readmitted to a different hospital from where their bariatric surgery was performed. Risk factors for 30-day VTE readmission were RYGB, hospitalization more than seven days, more than 65 years of age, Medicaid insurance, and surgery performance at a for-profit hospital. Unique risk factors for admission to another hospital were Medicare insurance, chronic obstructive pulmonary disease (COPD), and liver disease.

Scientific Bariatric Forum III, moderated by Patricia Chui, MD, and Dan Azagury, MD, featured a presentation from the Geisinger group in Danville, Pennsylvania, titled “Equivalent Perioperative Outcomes for Laparoscopic RYGB Patients Discharged on Postoperative Day One.” After reviewing data from their prospective database, a multipoint checklist of preoperative criteria were used to identify candidates for discharge on Postoperative Day 1 (POD1), which included: 1)less than 65 years of age; 2) residence less than 90 minutes away; 3) no therapeutic anticoagulation; 4) no major cardiac, pulmonary, or renal disease; and 5) the ability to independently ambulate 200 feet. Using these criteria, they were able to discharge 55.9 percent of patients on POD1, verses 16.6 percent prior to implementation (p<0.0001) Emergency room and readmission rate was 13 percent in those discharged on POD1 compared to 10 percent for those discharged after POD1, but when this group was matched for patients with similar age/body mass index (BMI)/comorbidities, the readmission rate became equivalent. Additionally, there were no observed differences in mortality, or major/minor complications, aside from a reduction in postoperative pulmonary complications (2.5% vs 1.1%, p=0.048).

A paper from University of Utah was presented during Forum IV on patient reported outcomes improvement using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire for patients after bariatric surgery. Patients used a digital tablet or other electronic communication to answer questions before and after either RYGB or laparoscopic sleeve gastrectomy (LSG) regarding depression, satisfaction with social roles, pain interference, physical function, general health, and gastroesophageal reflux disease health-related quality of life (GERD-HRQL). All quality-of-life measures showed significant improvement postoperatively after both procedures, except for GERD-HRQL after LSG. Mean improvement was greater for all measures after LRYGB compared to LSG.The data reported was short term but showed improvement in both physical and emotional well-being. Although follow up was only about four months, the methodology is a novel approach to improving our understanding of patient reported outcomes. Also in the fourth session was a paper from Stanford that specifically looked at preoperative weight loss and its effect on surgical outcomes. Using 2016 Metabolic and Bariatric Surgery Accreditation and Quality Program (MBSAQIP) public use file (PUF), the researchers compared the outcomes of more than 134,000 patients undergoing primary LSG or RYGB. They found no difference in all-cause, 30-day mortality, complications, or reoperations. However, odds of readmission was reduced by eight percent in patients with preoperative weight loss, suggesting an overall benefit to these patients.

Finally, the ACS recognized the 2018 Excellence in Research Award Recipients. We would like to extend our congratulations to all recipients, especially to David Harris, MD, who won in the Bariatric and Foregut category, for his paper on enhanced system and intestinal glucose metabolism after LSG independent of weight loss.

Next month: Overview of Obesity Week 2018

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Category: Past Articles, Raising the Standard

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