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Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study

  • 2018 SAGES Oral
  • Published:
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Abstract

Background

Considerable technical variation exists when performing laparoscopic sleeve gastrectomy (LSG). However, little is known about which techniques are associated with optimal outcomes.

Objective

To compare technical variation among surgeons with the lowest complication rates and whose patients achieved the most weight loss.

Methods

Practicing bariatric surgeons (n = 30) voluntarily submitted a video of a typical LSG performed between 2015 and 2016. Technique-specific data captured from videos and a questionnaire included bougie size, stapler vendor, number of staple loads, use of staple line reinforcement, fibrin sealant, intraoperative leak test, endoscopy, and drain placement. Surgeon-specific outcomes were obtained from cases performed by surgeons during the study period (n = 7023) using a state-wide bariatric-specific data registry. Surgeons were ranked based on 30-day risk-adjusted surgical complication rates (“safety”) and excess body weight loss (EBWL) % (“efficacy”) at 1 year after surgery. Technique-specific variables were compared between surgeons ranked in the top and bottom quartile for both safety and efficacy.

Results

Surgical complication rates ranged from 0 to 4.32% while EBWL varied from 45.3 to 65.3%. There was no correlation between surgeon rankings for safety and efficacy (Pearson’s r = 0.063, p = 0.741). Surgeons ranked in the top quartile for safety and efficacy had significantly shorter mean operative times than surgeons ranked in the bottom quartile (65 min vs. 69 min, p < 0.0001). Surgeons with the highest leak rates were more likely to use buttressing (85.7% vs 40.0%, p = 0.032), otherwise operative techniques varied considerably.

Conclusions

Technical variation appears to have minimal effect on the safety or efficacy of sleeve gastrectomy among surgeons participating in a state-wide quality improvement collaborative. Top ranked surgeons did have faster mean operative times indicating that there may be other metrics of technical quality that correlate to optimal outcomes.

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References

  1. Esteban Varela J, Nguyen NT (2015) Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis 11:987–990

    Article  PubMed  Google Scholar 

  2. Nguyen NT, Vu S, Kim E, Bodunova N, Phelan MJ (2016) Trends in utilization of bariatric surgery, 2009–2012. Surg Endosc 30:2723–2727

    Article  PubMed  Google Scholar 

  3. Akkary E, Duffy A, Bell R (2008) Deciphering the sleeve: technique, indications, efficacy, and safety of sleeve gastrectomy. Obes Surg 18:1323–1329

    Article  PubMed  Google Scholar 

  4. Berger ER, Clements RH, Morton JM, Huffman KM, Wolfe BM, Nguyen NT, Ko CY, Hutter MM (2016) The impact of different surgical techniques on outcomes in laparoscopic sleeve gastrectomies: the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Ann Surg 264:464–473

    Article  PubMed  Google Scholar 

  5. Rosenthal RJ, International SGEP, Diaz AA, Arvidsson D, Baker RS, Basso N, Bellanger D, Boza C, El Mourad H, France M, Gagner M, Galvao-Neto M, Higa KD, Himpens J, Hutchinson CM, Jacobs M, Jorgensen JO, Jossart G, Lakdawala M, Nguyen NT, Nocca D, Prager G, Pomp A, Ramos AC, Rosenthal RJ, Shah S, Vix M, Wittgrove A, Zundel N (2012) International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of> 12,000 cases. Surg Obes Relat Dis 8:8–19

    Article  PubMed  Google Scholar 

  6. Varban OA, Niemann A, Stricklen A, Ross R, Ghaferi AA, Finks JF, Dimick JB (2017) Far from standardized: using surgical videos to identify variation in technique for laparoscopic sleeve gastrectomy. J Laparoendosc Adv Surg Tech A 27:761–767

    Article  PubMed  Google Scholar 

  7. Aurora AR, Khaitan L, Saber AA (2012) Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 26:1509–1515

    Article  PubMed  Google Scholar 

  8. D’Ugo S, Gentileschi P, Benavoli D, Cerci M, Gaspari A, Berta RD, Moretto C, Bellini R, Basso N, Casella G, Soricelli E, Cutolo P, Formisano G, Angrisani L, Anselmino M (2014) Comparative use of different techniques for leak and bleeding prevention during laparoscopic sleeve gastrectomy: a multicenter study. Surg Obes Relat Dis 10:450–454

    Article  PubMed  Google Scholar 

  9. Gagner M, Buchwald JN (2014) Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review. Surg Obes Relat Dis 10:713–723

    Article  Google Scholar 

  10. Gill RS, Switzer N, Driedger M, Shi X, Vizhul A, Sharma AM, Birch DW, Karmali S (2012) Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients. Obes Surg 22:560–564

    Article  PubMed  Google Scholar 

  11. Varban OA, Sheetz KH, Cassidy RB, Stricklen A, Carlin AM, Dimick JB, Finks JF (2017) Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study. Surg Obes Relat Dis 13:560–567

    Article  PubMed  Google Scholar 

  12. Gagner M, Hutchinson C, Rosenthal R (2016) Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis 12:750–756

    Article  PubMed  Google Scholar 

  13. Bellanger DE, Greenway FL (2011) Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 21:146–150

    Article  PubMed  Google Scholar 

  14. Huang R, Gagner M (2015) A thickness calibration device is needed to determine staple height and avoid leaks in laparoscopic sleeve gastrectomy. Obes Surg 25:2360–2367

    Article  PubMed  PubMed Central  Google Scholar 

  15. Birkmeyer JD, Finks JF, O’Reilly A, Oerline M, Carlin AM, Nunn AR, Dimick J, Banerjee M, Birkmeyer NJ, Michigan BSC (2013) Surgical skill and complication rates after bariatric surgery. N Engl J Med 369:1434–1442

    Article  CAS  Google Scholar 

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Funding

SAGES Career Development Award 2016.

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Authors and Affiliations

  1. Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA

    Oliver A. Varban MD, Jonathan F. Finks, Amir A. Ghaferi & Justin B. Dimick

  2. Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA

    Jyothi R. Thumma, Jonathan F. Finks, Amir A. Ghaferi & Justin B. Dimick

  3. Department of Surgery, Henry Ford Health System, Detroit, MI, USA

    Arthur M. Carlin

  4. Department of Surgery, Grand Health Partners, Grand Rapids, MI, USA

    Paul R. Kemmeter

  5. Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Drive, SPC 5343, Ann Arbor, MI, 48109-5343, USA

    Oliver A. Varban MD

Authors
  1. Oliver A. Varban MD
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  2. Jyothi R. Thumma
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  3. Jonathan F. Finks
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  4. Arthur M. Carlin
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  5. Paul R. Kemmeter
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  6. Amir A. Ghaferi
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  7. Justin B. Dimick
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Corresponding author

Correspondence to Oliver A. Varban MD.

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Disclosures

Oliver A. Varban, MD: Receives salary support from Blue Cross/Blue Shield of Michigan for leadership and participation in quality improvement initiatives within the Michigan Bariatric Surgery Collaborative. Jonathan F. Finks, MD: Receives salary support from Blue Cross/Blue Shield of Michigan for role as Associate Director of the Michigan Bariatric Surgery Collaborative. Arthur M. Carlin, MD: Receives an honorarium from Blue Cross/Blue Shield of Michigan for Executive Committee Chair of the Michigan Bariatric Surgery Collaborative. Paul R. Kemmeter, MD Receives stipends from W. L. Gore & Associates for educational presentations. Amir (A) Ghaferi, MD, MS: Receives funding from Blue Cross/Blue Shield of Michigan for leadership in the Michigan Bariatric Surgery Collaborative. Justin (B) Dimick, MD, MPH: Receives grants and participates in NIH study sections; is an equity owner of ArborMetrix, Inc. and receives honorariums from academic health centers for giving grand rounds lectures. Jyothi R. Thumma, MPH have nothing to disclose.

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Varban, O.A., Thumma, J.R., Finks, J.F. et al. Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study. Surg Endosc 33, 895–903 (2019). https://doi.org/10.1007/s00464-018-6382-y

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  • DOI: https://doi.org/10.1007/s00464-018-6382-y

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