Abstract
Background
Bariatric surgery is expanding and the increasing workload needs to be undertaken safely in new surgical centres with no previous bariatric experience. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has a steep learning curve with documented high risk. We present the results for the first 300 cases of LRYGB in a new centre.
Methods
Three hundred consecutive patients underwent LRYGB performed by a single surgeon. Four external surgeons mentored eight cases in the first 50. Demographic characteristics, body mass index (BMI) and operative time were collected prospectively and the Obesity Surgery Mortality Risk Score was used for risk stratification.
Results
The mean BMI of the patients increased during the series from 49.0 for the first group to 50.2 for the second group and to 51.0 for the third group (p < 0.05). The number of high-risk patients measured with the OS-MRS was 19/300 (6.3%) in the whole series. The mean operative time decreased from 163 min for the first 100 patients to 119 min for the second 100 and 94 for the third (p < 0.0001). In the first group, there were nine reoperations and two conversions to open surgery, compared to two reoperations and one conversion in the second group (p < 0.05). In the whole series, there were 12 early complications requiring re-operation, four conversions to open surgery and one mortality (patient 110, heart failure within 24 h).
Conclusions
A mentoring process ensures that LRYGB can be done safely in a newly established bariatric centre. The operative time reduces markedly after the learning curve.
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References
Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery a systematic review and meta-analysis. JAMA. 2004;292:1724–37.
Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004;14:1157–64.
Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357:753–61.
Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. Am Coll Surg. 2004;199:543–51.
Snow V, Barry P, Fitterman N, et al. Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2005;142:525–31.
Melissas J. IFSO guidelines for safety, quality, and excellence in bariatric surgery. Obes Surg. 2008;18:497–500.
Pratt GM, McLees B, Pories WJ. The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement. Surg Obes Relat Dis. 2006;2:497–503.
Abu-Hilal M, Vanden Bossche M, Bailey IS, et al. A two-consultant approach is a safe and efficient strategy to adopt during the learning curve for laparoscopic Roux-en-Y gastric bypass: our results in the first 100 procedures. Obes Surg. 2007;17:742–6.
DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass. Surg Obes Relat Dis. 2007;3:134–40.
Higa KD, Boone KB, Ho T, et al. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients. Arch Surg. 2000;135:1029–33.
DeMaria EJ, Murr M, Byrne TK, et al. Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg. 2007;246:578–82.
Suter M, Paroz A, Calmes JM, et al. European experience with laparoscopic Roux-en-Y gastric bypass in 466 obese patients. Br J Surg. 2006;93:726–32.
Shikora SA, Kim JJ, Tarnoff ME, et al. Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program. Arch Surg. 2005;140:362–7.
Andrew CG, Hanna W, Look D, et al. Early results after laparoscopic Roux-en-Y gastric bypass: effect of the learning curve. Can J Surg. 2006;49:417–21.
Schauer P, Ikramuddin S, Hamad G, et al. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc. 2003;17:212–5.
Breaux JA, Kennedy CI, Richardson WS. Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2007;21:985–8.
Oliak D, Ballantyne GH, Weber P, et al. Laparoscopic Roux-en-Y gastric bypass: defining the learning curve. Surg Endosc. 2003;17:405–8.
Lublin M, Lyass S, Lahmann B, et al. Leveling the learning curve for laparoscopic bariatric surgery. Surg Endosc. 2005;19:845–8.
Søvik TT, Aasheim ET, Kristinsson J, et al. Establishing laparoscopic Roux-en-Y gastric bypass: perioperative outcome and characteristics of the learning curve. Obes Surg. 2009;19:158–65.
Stoopen-Margain E, Fajardo R, España N, et al. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: results of our learning curve in 100 consecutive patients. Obes Surg. 2004;14:201–5.
Huang CK, Lee YC, Hung CM, et al. Laparoscopic Roux-en-Y gastric bypass for morbidly obese Chinese patients: learning curve, advocacy and complications. Obes Surg. 2008;18:776–81.
Larsen CR, Soerensen JL, Grantcharov TP, et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ. 2009;338:b1802.
Funding Support
DJ Pournaras is funded by a Royal College of Surgeons of England Research Fellowship.
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The authors have no other conflict of interest to disclose.
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Pournaras, D.J., Jafferbhoy, S., Titcomb, D.R. et al. Three Hundred Laparoscopic Roux-en-Y Gastric Bypasses: Managing the Learning Curve in Higher Risk Patients. OBES SURG 20, 290–294 (2010). https://doi.org/10.1007/s11695-009-9914-7
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DOI: https://doi.org/10.1007/s11695-009-9914-7