Evaluation of operating room inefficiencies and their impact on operating room duration using a surgical app.

BACKGROUND: Efficient utilization of the operating room (OR) is essential. Inefficiencies are thought to cause preventable delays. Our goal was to identify OR incidents causing delays and estimate their impact on the duration of various general surgery procedures. MATERIALS: Three trained observers prospectively collected intraoperative data using the ExplORer Surgical app, a tool that helped capture incidents causing delays. The impact of each incident on case duration was assessed using multivariable analysis. RESULTS: 151 general surgery procedures were observed. The mean number of incidents was 2.7 per each case that averaged 109min. On average, each incident caused a 2.8 â€‹min delay (p â€‹< â€‹0.001), however, some incidents were associated with longer delays. The procedural step of each procedure most susceptible to incidents was also defined. CONCLUSION: The identification of the type of incidents and the procedural step during which they occur may allow targeted interventions to optimize OR efficiency and decrease operative time.

What delays your case start? Exploring operating room inefficiencies.

INTRODUCTION: Improving operating room (OR) inefficiencies benefits the OR team, hospital, and patients alike but the available literature is limited. Our goal was, using a novel surgical application, to identify any OR incidents that cause delays from the time the patient enters the OR till procedure start (preparatory phase). MATERIALS AND METHODS: We conducted an IRB approved, prospective, observational study between July 2018 and January 2019. Using a novel surgical application (ExplORer Surgical) three observers recorded disrupting incidents and their duration during the preparatory phase of a variety of general surgery cases. Specifically, the number and duration of anesthesia delays, unnecessary/distracting conversations, missing items, and other delays were recorded from the moment they started until they stopped affecting the normal workflow. RESULTS: Ninety-six OR cases were assessed. 20 incidents occurred in 18 (19%) of those cases. The average preparatory duration for all the cases was 20.7 ± 8.6 min. Cases without incidents lasted 19.5 ± 7.4 min while cases with incidents lasted 25.9 ± 11.2 min, p = 0.03. The average incident lasted 3.7 min, approximately 18% of the preparatory phase duration. CONCLUSION: The use of the ExplORer Surgical app allowed us to accurately record the incidents happening during the preparatory phase of various general surgery operations. Such incidents significantly prolonged the preparatory duration. The identification of those inefficiencies is the first step to targeted interventions that may eventually optimize the efficiency of preoperative preparation.

Travel distance reduces follow-up compliance but has no effect on long-term weight loss success in bariatric patients.

BACKGROUND: Patients seeking bariatric surgery are traveling longer distances to reach Bariatric Centers. The purpose of this study was to evaluate the impact of travel distance on adherence to follow-up and outcomes after bariatric surgery. METHODS: A retrospective review of all consecutive patients who had undergone bariatric surgery from June 2013 to May 2014 was performed, and the patients were divided into two groups: those who traveled 50 miles or less and those who traveled more than 50 miles. Primary outcome assessed was the influence of distance on post-operative follow-up attrition over 4-year period. Secondary outcomes assessed were excess weight loss, length of stay (LOS), complications and readmission rates. RESULTS: A total of 228 patients underwent bariatric surgery with 4 years of follow-up available. Of these, 145 patients traveled 50 miles or less and 83 patients traveled greater than 50 miles. Patient demographics were similar between the two groups. Those who traveled more had statistically higher probability of attrition up to 3-year follow-up mark. There was no difference in percent excess weight loss at each follow-up visit between the two cohorts. Furthermore, there was no difference in readmission rates (2% vs 5%), minor complications (14% vs 10%), major complications (3% vs 2%) and LOS (2.6 days vs 2.6). CONCLUSION: The distance patients traveled for bariatric surgery did not affect their weight loss success, length of stay, postsurgical complications or readmission rate. Despite the lack of influence on postoperative outcomes, follow-up compliance was statistically affected by distance.

Comparison of operating room inefficiencies and time variability in laparoscopic gastric bypass.

BACKGROUND: Improving operating room (OR) inefficiencies has financial and operational ramifications. However, their incidence has not been systematically studied, especially in bariatric surgery. OBJECTIVES: The study aimed to identify the operational inefficiencies of the laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure, specify the steps of the procedure, and investigate whether the inefficiencies are related to case-by-case variability, using a surgical application. SETTING: University Hospital, United States METHODS: From July 2018 to January 2019, we observed consecutive nonrevisional LRYGB cases. We used a surgical application to capture in real-time all the inefficiencies/incidents that occurred inside the operating room. The duration and time variability, along with the number of incidents of each step, were recorded. Additionally, a multivariable analysis was conducted to investigate whether patient factors (age, race, body mass index, and American Society of Anesthesiologists physical status classification), surgeon and surgical-technician experience, resident-assist, and case difficulty affect the number of incidents. RESULTS: Forty LRYGB procedures were observed. The duration of the procedural steps was linearly correlated with the number of incidents but case-to-case step duration variability was not. The steps that were linked with more inefficiencies included jejunojejunostomy creation that included more unrelated to the case conversations, and gastric pouch creation that had more anesthesia-related delays. Inefficiencies such as equipment malfunctions and missing supplies were equally distributed among all the steps. Multivariable analysis did not indicate that any of the tested factors were associated with the number of incidents. CONCLUSION: The use of the surgical app allowed us to accurately record the duration, variability, and the undesired incidents of each LRYGB procedural step. Future studies should target interventions to minimize the inefficient procedural steps we have identified to optimize operating room efficiency.

Do Mandated Weight Loss Goals Prior to Bariatric Surgery Improve Postoperative Outcomes?

BACKGROUND: Most patients pursuing bariatric surgery undergo mandated preoperative weight management programs. The purpose of this study was to assess whether preoperative mandated weight loss goals lead to improved perioperative morbidity, postoperative weight loss, and resolution of comorbidities. METHODS: Data from patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic sleeve gastrectomy (LSG) between October 2012 and October of 2015 was reviewed. Patients were divided in two groups: those with BMI of 35-45 were not required to achieve a weight loss goal prior to surgery (no-WLG group) while those with BMI > 45 were given a weight loss goal proportionate to their weight (WLG group). Body mass index (BMI), history of diabetes mellitus type-II (DM-II), hypertension (HTN), hyperlipidemia (HLD), and obstructive sleep apnea (OSA) were recorded at baseline and 4 years postoperatively. Length of hospital stay (LOS) and reinterventions were considered proxies for postoperative morbidity. RESULTS: A total of 776 patients, 81.4% LRYGB, were included in the study (age 45.1 ± 11.9). There was no difference in %ΔBMI, DM-II, HDL, HTN, LOS, or reinterventions among the two groups at 4 years postoperatively in both LRNY and LSG patients. This lack of difference persisted even when patients with similar BMI (43-45 vs 45.01-47) were compared. CONCLUSION: WLG group did not have decreased perioperative morbidity, nor improved weight loss and comorbidity resolution 4 years after surgery. While these findings should also be confirmed by multicenter trials, they question the value of mandated WLG prior to bariatric surgery as they seem ineffective and may limit patient access to surgery.

Development of ASMBS research agenda for bariatric surgery using the Delphi methodology.

BACKGROUND: While the number of research publications related to bariatric surgery have increased remarkably in the past decade, research efforts remain uncoordinated and have limited focus, and numerous important questions remain unanswered. OBJECTIVE: To generate a research agenda in bariatric surgery. SETTING: National survey. METHODS: The membership of the American Society of Metabolic and Bariatric Surgery (ASMBS) was asked to submit research questions needed to advance the field of bariatric surgery. An expert panel grouped and collated submitted questions and redistributed them back to the membership to rate their importance on a 5-point Likert scale using a 3-round modified Delphi methodology. The top research questions were determined based on provided rankings. RESULTS: Two hundred ninety-two research questions were initially submitted that were collapsed to 59 unique questions. The ratings for the top 40 questions ranged from 2.67-4.33 (overall mean, 3.46). The highest-ranked questions centered on the mechanisms of effectiveness of bariatric surgery for weight loss and diabetes resolution, the underlying etiology of weight recidivism, and predictors of success. CONCLUSIONS: A research agenda for bariatric surgery was developed using the Delphi methodology. This research agenda may enhance the ability of investigators and funding organizations, including the ASMBS, to focus attention to areas most likely to advance the field, and by editors and reviewers to assess the merit and relevance of scientific contributions.

Web-Based Educational Seminars Compare Favorably with In-House Seminars for Bariatric Surgery Patients.

BACKGROUND: Comprehensive preparative patient education is a key element in bariatric patient success. The primary objective of this study was to compare attrition rates, demographics, and surgery outcomes between patients who participated in the online vs in-house preparative seminars. METHODS: A retrospective chart review was performed involving patients who chose to participate in online vs in-house educational seminar between July of 2014 and December of 2016. The patients were divided into two groups based on their choice of educational seminar and tracked to see how many made it to an initial visit and to surgery. In those who had bariatric surgery, data was collected on age, type of insurance, length of stay (LOS), longest follow-up, and change in body mass index. RESULTS: Total of 1230 patients were included in this study. There was no difference in attrition rate to initial consultation visit (29.1% vs 29.9%), but there was a statistically higher attrition to surgery in the in-house seminar attendees (72.9%) compared to online participants (66.6%, p < 0.05). Between January 2015 and December 2016, 291 patients underwent primary bariatric surgery. The online group was on average 3 years younger which was statistically significant. There were no differences in LOS, longest follow-up, and weight loss at 12 months between the groups. CONCLUSION: When comparing attrition rates and bariatric surgery outcomes, no overall difference was noted between patients who received web- or hospital-based preparative education. Bariatric programs should provide access to online seminars to attract younger population and save resources and cost.

A behavioral rating system predicts weight loss and quality of life after bariatric surgery.

BACKGROUND: Bariatric surgery represents the most effective intervention for severe obesity available today; however, significant variability in postoperative outcomes exists. Effective tools that predict postoperative outcomes are needed for decision-making and patient counseling. OBJECTIVES: We hypothesized that a validated behavioral assessment tool, the Cleveland Clinic Behavioral Rating Scale (CCBRS), would predict excess weight loss, health-related quality of life, depression, anxiety, and alcohol use after bariatric surgery. SETTING: Hospital in the United States. METHODS: A prospective observational study with 2-year planned follow-up was conducted with patients who completed a psychological clinical interview, the Short Form 36 (SF-36) v.2 Health Survey and brief self-report questionnaires measuring depression (PHQ-9), anxiety (GAD-7), and alcohol use (AUDIT) preoperatively. At the conclusion of the preoperative psychological evaluation, the psychologist completed the CCBRS. All questionnaires were readministered at 6, 12, 18, and 24 months after surgery. Generalized estimating equations were used to assess whether any CCBRS ratings predicted surgery outcomes. RESULTS: One hundred seventy-nine patients (113 Roux-en-Y gastric bypass and 66 sleeve gastrectomy) were included in the analyses. SF-36 scores, PHQ-9 scores, and the AUDIT total scores improved significantly after surgery, while GAD-7 scores did not change appreciably. Higher preoperative CCBRS ratings predicted higher SF-36 scores, and lower PHQ-9, GAD-7 and AUDIT scores. The CCBRS social support rating predicted higher postoperative percent excess weight loss. CONCLUSION: A behavioral rating scale (CCBRS) completed before bariatric surgery predicted postoperative weight loss, quality of life, depression, and anxiety. Therefore, this tool may prove useful in patient counseling and expectation management before surgery.

Risk reduction and survival benefit of prophylactic surgery in BRCA mutation carriers, a systematic review.

BACKGROUND: Mutations in BRCA1 or BRCA2 genes results in an elevated risk for developing both breast and ovarian cancers over the lifetime of affected carriers. General surgeons may be faced with questions about surgical risk reduction and survival benefit of prophylactic surgery. METHODS: A systematic literature review was performed using the electronic databases PubMed, OVID MEDLINE, and Scopus comparing prophylactic surgery vs observation with respect to breast and ovarian cancer risk reduction and mortality in BRCA mutation carriers. RESULTS: Bilateral risk-reducing mastectomy provides a 90% to 95% risk reduction in BRCA mutation carriers, although the data do not demonstrate improved mortality. The reduction in ovarian and breast cancer risks using risk-reducing bilateral salpingo-oophorectomy has translated to improvement in survival. CONCLUSIONS: Clinical management of patients at increased risk for breast cancer requires consideration of risk, patient preference, and quality of life.

Cardiac recurrence in a patient with long-term survival from metastatic colon cancer.

Metastatic colorectal cancer represents a major health problem in the US and worldwide. Forty percent of patients undergoing resection of the primary tumor will experience relapse. In this brief review, we describe a case of a woman with metastatic disease and long-term survival culminating with an unusual myocardial recurrence. Over three decades, a multimodality approach has evolved to allow for long-term survival in selected patients with metastatic colorectal cancer. In this case report, the role of multiple aggressive surgical resections is emphasized.