Performance of artificial intelligence in bariatric surgery: comparative analysis of ChatGPT-4, Bing, and Bard in the American Society for Metabolic and Bariatric Surgery textbook of bariatric surgery questions.

BACKGROUND: The American Society for Metabolic and Bariatric Surgery (ASMBS) textbook serves as a comprehensive resource for bariatric surgery, covering recent advancements and clinical questions. Testing artificial intelligence (AI) engines using this authoritative source ensures accurate and up-to-date information and provides insight in its potential implications for surgical education and training. OBJECTIVES: To determine the quality and to compare different large language models' (LLMs) ability to respond to textbook questions relating to bariatric surgery. SETTING: Remote. METHODS: Prompts to be entered into the LLMs were multiple-choice questions found in "The ASMBS Textbook of Bariatric Surgery, second Edition. The prompts were queried into 3 LLMs: OpenAI's ChatGPT-4, Microsoft's Bing, and Google's Bard. The generated responses were assessed based on overall accuracy, the number of correct answers according to subject matter, and the number of correct answers based on question type. Statistical analysis was performed to determine the number of responses per LLMs per category that were correct. RESULTS: Two hundred questions were used to query the AI models. There was an overall significant difference in the accuracy of answers, with an accuracy of 83.0% for ChatGPT-4, followed by Bard (76.0%) and Bing (65.0%). Subgroup analysis revealed a significant difference between the models' performance in question categories, with ChatGPT-4's demonstrating the highest proportion of correct answers in questions related to treatment and surgical procedures (83.1%) and complications (91.7%). There was also a significant difference between the performance in different question types, with ChatGPT-4 showing superior performance in inclusionary questions. Bard and Bing were unable to answer certain questions whereas ChatGPT-4 left no questions unanswered. CONCLUSIONS: LLMs, particularly ChatGPT-4, demonstrated promising accuracy when answering clinical questions related to bariatric surgery. Continued AI advancements and research is required to elucidate the potential applications of LLMs in training and education.

Preoperative depression and outcomes after metabolic and bariatric surgery: A systematic narrative review.

Preoperative depression is prevalent among patients undergoing metabolic and bariatric surgery (MBS) and is a potentially modifiable risk factor. However, the impact of preoperative depression on MBS outcomes has not been systematically reviewed. A search of MEDLINE, Embase, Cochrane, and PsychINFO (inception to June 2023) was conducted for studies reporting associations between preoperative depression and any clinical or patient-reported outcomes after MBS. Eighteen studies (5 prospective and 13 retrospective) reporting on 5933 participants were included. Most participants underwent gastric bypass or sleeve gastrectomy. Meta-analyses were not conducted due to heterogeneity in reported outcomes; findings were instead synthesized using a narrative and tabular approach. Across 13 studies (n = 3390) the associations between preoperative depression and weight loss outcomes at 6-72 months were mixed overall. This may be related to differences in cohort characteristics, outcome definitions, and instruments used to measure depression. A small number of studies reported that preoperative depression was associated with lower quality of life, worse acute pain, and more perioperative complications after surgery. Most of the included studies were deemed to be at high risk of bias, resulting in low or very low certainty of evidence according to the Risk of Bias In Non-randomized Studies - of Exposure (ROBINS-E) tool. While the impact of preoperative depression on weight loss after MBS remains unclear, there is early evidence that depression has negative consequences on other patient-important outcomes. Adequately powered studies using more sophisticated statistical methods are needed to accurately estimate these associations.

Does routine upper gastrointestinal swallow study after metabolic and bariatric surgery lead to earlier diagnosis of leak?

BACKGROUND: It is unclear whether routine upper gastrointestinal swallow study (SS) in the immediate postoperative period is associated with earlier diagnosis of gastrointestinal leak after bariatric surgery. OBJECTIVE: To investigate the relationship between routine SS and time to diagnosis of postoperative gastrointestinal leak. SETTING: MBSAQIP-accredited hospitals in the United States and Canada. METHODS: We conducted an observational cohort study of adults who underwent laparoscopic primary Roux-en-Y gastric bypass (RYGB) (n = 82,510) and sleeve gastrectomy (SG) (n = 283,520) using the MBSAQIP 2015-2019 database. Propensity scores were used to match patient cohorts who underwent routine versus no routine SS. Primary outcome was time to diagnosis of leak. Median days to diagnosis of leak were compared. The Nelson-Aalen estimator was used to determine the cumulative hazards of leak. RESULTS: In our study, 36,280 (23%) RYGB and 135,335 (33%) SG patients received routine SS. Routine SS was not associated with earlier diagnosis of leak (RYGB routine SS median 7 [IQR 3-12] days v. no routine SS 6 [2-11] days, P = .9; SG routine SS 15 [9-22] days v. no routine SS 14 [8-21] days, P = .06) or lower risk of developing leak (RYGB HR 1.0, 95%-CI .8-1.2; SG HR 1.1, 95%-CI 1.0-1.4). More routine SS patients had a length of stay 2 days or greater (RYGB 78.3% v. 61.1%; SG 48.6% v. 40.3%). CONCLUSIONS: Routine SS was not associated with earlier diagnosis of leaks compared to the absence of routine SS. Surgeons should consider abandoning the practice of routine SS for the purpose of obtaining earlier diagnosis of postoperative leaks.

Early Discharge after Uncomplicated Elective Colectomy and Risk of Postdischarge Complication.

BACKGROUND: This was a retrospective cohort study of adult patients undergoing uncomplicated elective colectomy using the NSQIP database from January 2012 to December 2019. A colectomy is deemed uncomplicated if there are no complications reported during the hospitalization. The objective of this study was to examine the association between discharge timing and postdischarge complications in patients who undergo uncomplicated elective colectomy. STUDY DESIGN: Patients were stratified into an early discharge group if their length of postoperative hospitalization was ≤3 days for laparoscopic or robotic approaches, or ≤5 days for the open approach, and otherwise into delayed discharge groups. The association between early discharge and any postdischarge complication was examined using unadjusted logistic regression after propensity score matching between early and delayed discharge groups. RESULTS: Of the 113,940 patients included, 77,979, 15,877, and 20,084 patients underwent uncomplicated laparoscopic, robotic, and open colectomy, respectively. After propensity score matching, the odds of a postdischarge complication were lower for the early discharge group in laparoscopic (odds ratio 0.73, 95% CI 0.68 to 0.79) and robotic (odds ratio 0.63, 95% CI 0.52 to 0.76) approaches, and not different in the open approach (odds ratio 1.02, 95% CI 0.91 to 1.15). There were no clinically meaningful differences in the risk of return to the operating room for all surgical approaches. CONCLUSIONS: Early discharge after uncomplicated colectomy appears to be safe and is associated with lower odds of postdischarge complications in minimally invasive approaches. Our findings suggest that surgical teams practice sound clinical judgments on selecting patients who benefit from early discharge.

Severity Grading Systems for Intraoperative Adverse Events. A Systematic Review of the Literature and Citation Analysis.

INTRODUCTION: The accurate assessment and grading of adverse events (AE) is essential to ensure comparisons between surgical procedures and outcomes. The current lack of a standardized severity grading system may limit our understanding of the true morbidity attributed to AEs in surgery. The aim of this study is to review the prevalence in which intraoperative adverse event (iAE) severity grading systems are used in the literature, evaluate the strengths and limitations of these systems, and appraise their applicability in clinical studies. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. PubMed, Web of Science, and Scopus were queried to yield all clinical studies reporting the proposal and/or the validation of iAE severity grading systems. Google Scholar, Web of Science, and Scopus were searched separately to identify the articles citing the systems to grade iAEs identified in the first search. RESULTS: Our search yielded 2957 studies, with 7 studies considered for the qualitative synthesis. Five studies considered only surgical/interventional iAEs, while 2 considered both surgical/interventional and anesthesiologic iAEs. Two included studies validated the iAE severity grading system prospectively. A total of 357 citations were retrieved, with an overall self/nonself-citation ratio of 0.17 (53/304). The majority of citing articles were clinical studies (44.1%). The average number of citations per year was 6.7 citations for each classification/severity system, with only 2.05 citations/year for clinical studies. Of the 158 clinical studies citing the severity grading systems, only 90 (56.9%) used them to grade the iAEs. The appraisal of applicability (mean%/median%) was below the 70% threshold in 3 domains: stakeholder involvement (46/47), clarity of presentation (65/67), and applicability (57/56). CONCLUSION: Seven severity grading systems for iAEs have been published in the last decade. Despite the importance of collecting and grading the iAEs, these systems are poorly adopted, with only a few studies per year using them. A uniform globally implemented severity grading system is needed to produce comparable data across studies and develop strategies to decrease iAEs, further improving patient safety.

Black-versus-White racial disparities in 30-day outcomes at Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited centers: a needed quality indicator.

BACKGROUND: Creating a metric in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to assess Black-versus-White disparities is critical if we are to ensure equitable care for all. OBJECTIVE: To investigate Black-versus-White disparities while replicating MBSAQIP methodology with regard to covariates and modeling so that the results can serve as the foundation to create a benchmarked site-level Disparities Metric for MBSAQIP. SETTING: United States and Canada. METHODS: Across the 2015-2019 MBSAQIP cohorts, 543,976 adults underwent primary or revision sleeve gastrectomy or Roux-en-Y gastric bypass and were reported as either White or Black. Using a set of covariates derived from published MBSAQIP performance models, we performed multivariable logistic modeling with 10-fold cross-validation for the 11 outcomes evaluated in MBSAQIP Semiannual Reports, plus venous thromboembolism (VTE) and death. We analyzed primary and revision cases separately. RESULTS: After risk adjustment, Black patients experienced higher odds of all-occurrence morbidity (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19-1.25; P < .001), serious events (OR, 1.08; 95% CI, 1.04-1.13; P < .001), all-cause intervention (OR, 1.31; 95% CI, 1.24-1.37; P < .001), related intervention (OR, 1.29; 95% CI, 1.22-1.37; P < .001), all-cause readmission (OR, 1.37; 95% CI, 1.33-1.41; P < .001), related readmission (OR, 1.41; 95% CI, 1.36-1.46; P < .001), venous thromboembolism (OR, 1.49; 95% CI, 1.34-1.65; P < .001), and death (OR, 1.59; 95% CI, 1.34-1.89; P < .001) after primary procedures. Black patients experienced lower odds of morbidity (OR, .94; 95% CI, .91-.98; P = .004) and surgical-site infection (OR, .72; 95% CI, .66-.78; P < .001). CONCLUSIONS: Black patients experienced a higher risk for serious complications and required more readmissions, reoperations, and postoperative interventions. This study supports the creation of a site-level Disparities Metric for the MBSAQIP and provides the framework to do so.

Analyzing and Discussing Human Factors Affecting Surgical Patient Safety Using Innovative Technology: Creating a Safer Operating Culture.

INTRODUCTION: Surgical errors often occur because of human factor-related issues. A medical data recorder (MDR) may be used to analyze human factors in the operating room. The aims of this study were to assess intraoperative safety threats and resilience support events by using an MDR and to identify frequently discussed safety and quality improvement issues during structured postoperative multidisciplinary debriefings using the MDR outcome report. METHODS: In a cross-sectional study, 35 standard laparoscopic procedures were performed and recorded using the MDR. Outcome data were analyzed using the automated Systems Engineering Initiative for Patient Safety model. The video-assisted MDR outcome report reflects on safety threat and resilience support events (categories: person, tasks, tools and technology, psychical and external environment, and organization). Surgeries were debriefed by the entire team using this report. Qualitative data analysis was used to evaluate the debriefings. RESULTS: A mean (SD) of 52.5 (15.0) relevant events were identified per surgery. Both resilience support and safety threat events were most often related to the interaction between persons (272 of 360 versus 279 of 400). During the debriefings, communication failures (also category person) were the main topic of discussion. CONCLUSIONS: Patient safety threats identified by the MDR and discussed by the operating room team were most frequently related to communication, teamwork, and situational awareness. To create an even safer operating culture, educational and quality improvement initiatives should aim at training the entire operating team, as it contributes to a shared mental model of relevant safety issues.

The United States Experience with One Anastomosis Gastric Bypass at MBSAQIP-Accredited Centers.

PURPOSE: One anastomosis gastric bypass (OAGB) has emerged as a potentially safe and effective weight-loss procedure. Worldwide, OAGB is the third most commonly performed primary bariatric procedure, comprising 4% of the annual volume. In the USA, OAGB has yet to be endorsed as a primary bariatric procedure and can only be performed under research protocols or as a revision procedure. MATERIALS AND METHODS: We performed an observational cohort study to describe the preoperative, intraoperative, and postoperative characteristics of adult patients who underwent primary or revision OAGB from 2015 to 2019 at MBSAQIP centers. Exclusion criteria included emergent surgery, incomplete 30-day follow-up, and non-laparoscopic- or robotic approach. RESULTS: During the study period, 803,906 bariatric procedures were performed and 645 (0.08%) were OAGB. Among these, 436 (67.6%) were primary and 209 (32.4%) were revision OAGB. The mean operation time was 89 min (SD, 59) and 8% were performed using a robotic approach. The overall complication rate was 7.4% and there was one death (0.2%). The post-operative complication rates were generally higher than the early complication rate (3.4%) reported in the YOMEGA trial, an RCT from France. Revision OAGB had a longer mean operation time of 141 min (SD, 85, p < 0.001). CONCLUSION: Primary OAGB was a rarely performed bariatric procedure at MBSAQIP-accredited centers comprising only 0.05% compared to 4% worldwide. Future studies should compare safety of OAGB to that of established bariatric procedures like Roux-en-Y gastric bypass and sleeve gastrectomy.

The development and measurement properties of the trauma NOn-TECHnical skills (T-NOTECHS) scale: A scoping review.

PURPOSE: Conduct a scoping review to critically appraise the development and summarize the evidence on the measurement properties of T-NOTECHS including sensibility, reliability, and validity. METHODS: A literature search was performed using Pubmed and Ovid databases. Studies that described the development process of T-NOTECHS and primary studies that presented evidence of reliability and validity were identified and included. Measurement properties of T-NOTECHS was assessed and summarized under the following: scale development, sensibility, reliability, and validity. RESULTS: The literature search yielded 245 articles with 24 studies meeting inclusion criteria. The T-NOTECHS was developed with an acceptable robust methodology. It has good sensibility with adequate content, face validity, and feasibility. It is a reliable measure of non-technical skills in the setting of trauma video review, which improves with expert raters or extensive training. The T-NOTECHS is a valid discriminative and evaluative instrument that measures non-technical skills of multidisciplinary trauma teams. CONCLUSIONS: T-NOTECHS provides reliable and valid measurements of non-technical skills of trauma teams, particularly when assessing trauma video review and non-technical skills training interventions by expert raters.

Intraoperative leak test is associated with lower postoperative bleed rate in primary sleeve gastrectomy: a propensity matched analysis of primary and revision bariatric surgery using the MBSAQIP database.

BACKGROUND: Gastrointestinal leaks after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) occur infrequently but lead to clinical and socioeconomic burden on patients. Surgeons perform intraoperative leak test (IOLT) via gastric tube or endoscopy to help prevent postoperative leaks. However, there is knowledge gap in the literature on effectiveness of IOLT during bariatric surgery. METHODS: In this observational cohort study using the 2015-2017 MBSAQIP database, we compared the outcomes in patients who received IOLT with those who did not during primary or revision RYGB and SG. The primary outcome was 30-day postoperative leak. Secondary outcomes were procedure duration and the rates of 30-day postoperative bleed, readmission, reoperation and intervention. Propensity score matching was used to assemble cohorts of patients with similar baseline characteristics. RESULTS: Among 363,042 patients, 82% underwent IOLT. Four subgroups of patients who underwent operations with or without IOLT during primary RYGB (n = 13,756), primary SG (n = 110,810), revision RYGB (n = 1140), and revision SG (n = 5576) had similar propensity scores and were matched 1:1. Patients who underwent IOLT had similar postoperative leak rates compared to those who did not (Primary RYGB with IOLT 0.7% v. without IOLT 0.6%; Primary SG 0.4% v. 0.3%; Revision RYGB 2.3% v. 1.0%; Revision SG 1.1% v. 0.7%). In primary SG subgroup, patients who underwent IOLT had lower postoperative bleed rates (0.6% v. 0.8%, p = 0.002). In primary RYGB and SG subgroups, operations with IOLT were slightly longer. CONCLUSION: Postoperative leak rates after primary and revision bariatric surgery were low and similar irrespective of IOLT. Patients who had IOLT during primary SG had lower postoperative bleed rates. Current judgment as to whether to perform an IOLT leads to excellent outcomes, and thus, current practices should continue. However, one should consider an IOLT during primary SG, not necessarily to reduce leak rates but to help reduce postoperative bleeding occurrences.

Comparison of Short-term Safety of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in the United States: 341 cases from MBSAQIP-accredited Centers.

BACKGROUND: One anastomosis gastric bypass (OAGB) is the third most common (4%) primary bariatric procedure worldwide but is seldom performed in the United States and is currently under consideration for endorsement by the American Society for Metabolic and Bariatric Surgery. Evidence from the United States on safety of OAGB compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is limited. OBJECTIVE: To compare the short-term safety outcomes of the three primary bariatric procedures. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited hospitals in the United States and Canada. METHODS: Using the 2015-2019 MBSAQIP database, we compared the safety outcomes of adult patients who underwent primary laparoscopic OAGB, RYGB, and SG. Exclusion criteria included age over 80 years, emergency operation, conversion, and incomplete follow-up. The primary outcome was 30-day overall complication. Secondary outcomes were 30-day surgical and medical complications and hospitalization length. RESULTS: A total of 341 patients underwent primary OAGB. Using propensity scores, we matched the OAGB cohort 1:1 with two cohorts of similar baseline characteristics who underwent RYGB and SG, respectively. The OAGB cohort had a lower overall complication rate than the RYGB cohort (6.7% versus12.3%, P = .02) and a similar rate to the SG cohort (5.0%, P = .43). The OAGB cohort had a similar rate of surgical complication to the RYGB cohort (5.0% versus 8.5%, P = .1) and a higher rate than the SG group (1.2%, P = .009). The OAGB cohort had a shorter median hospitalization than the RYGB cohort (1 d [interquartile range (IQR) 1-2 d] versus 2 d [IQR 1-2 d], P < .001) and a similar hospitalization length to the SG cohort ([1-2 d], P = .46). CONCLUSION: Using the largest and the most current U.S. data, this study demonstrated that the short-term safety profile of primary OAGB is acceptable, but future studies should determine the long-term safety.

Errors in adult trauma resuscitation: a systematic review.

INTRODUCTION: Trauma resuscitation at dedicated trauma centers typically consist of ad-hoc teams performing critical tasks in a time-limited manner. This creates a high stakes environment apt or avoidable errors. Reporting of errors in trauma resuscitation is generally center-dependent and lacks common terminology. METHODS: We conducted a systematic review by searching Ovid Medline, Scopus and Embase from inception to February 24, 2021 for errors in adult trauma resuscitation. English studies published after 2001 were included. Studies were assessed by two independent reviewers for meeting inclusion/exclusion criteria. Errors were characterized from the included studies and a summary table was developed. Our review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020152875). RESULTS: The literature search retrieved 4658 articles with 26 meeting eligibility criteria. Errors were identified by morbidity and mortality rounds or other committee in 62%, missed injuries on tertiary assessment or radiology review in 12%, deviations from algorithmic guidelines in 12% or predefined for chest tube complications, critical incident reporting, aspiration or delays in care. In total there were 39 unique error types identified and divided into 9 categories including Emergency Medical Services handover, airway, assessment of injuries, patient monitoring and access, transfusion/blood related, management of injuries, team communication/dynamics, procedure error and disposition. CONCLUSIONS: Overall, our systematic review identified 39 unique error types in trauma resuscitation. Identifying these errors is imperative in developing systems for improvement of trauma care.

System Factors Affecting Patient Safety in the OR: An Analysis of Safety Threats and Resiliency.

OBJECTIVE: The objective of this study is to determine the characteristics and frequency of intraoperative safety threats and resilience supports using a human factors measurement tool. BACKGROUND: Human factors analysis can provide insight into how system elements contribute to intraoperative adverse events. Empiric evidence on safety threats and resilience in surgical practice is lacking. METHODS: A cross-sectional study of 24 patients undergoing elective laparoscopic general surgery at a single center in the Netherlands from May to November, 2017 was conducted. Video, audio, and patient physiologic data from all included procedures were obtained through a multichannel synchronized recording device. Trained analysts reviewed the recordings and coded safety threats and resilience supports. The codes were categorized into 1 of 6 categories (person, task, tools and technology, physical environment, organization, and external environment). RESULTS: A median of 14 safety threats [interquartile range (IQR) 11-16] and 12 resilience supports (IQR 11-16) were identified per case. Most safety threat codes (median 9, IQR 7-12) and resilience support codes (median 10, IQR 7-12) were classified in the person category. The organization category contained a median of 2 (IQR 1-2) safety threat codes and 2 (IQR 2-3) resilience support codes per case. The tools and technology category contributed a small number of safety threats (median 1 per case, IQR 0-1), but rarely provided resilience support. CONCLUSIONS: Through a detailed human factors analysis of elective laparoscopic general surgery cases, this study provided a quantitative analysis of the existing safety threats and resilience supports in a modern endoscopic operating room.

Non-technical skills and device-related interruptions in minimally invasive surgery.

BACKGROUND: Device-related interruptions in the operating room (OR) may create stress among health care providers and delays. Although non-technical skills (NTS) of the OR teams, such as situational awareness and communication, are expected to influence device-related interruptions, empirical data on this relationship are limited. METHODS: We performed a prospective cohort study of 144 consecutive elective laparoscopic operations during 13 months. A data capture system called the OR Black Box® was used to characterize device-related interruptions, NTS, and distractions. Device-related interruptions were classified according to a priori established categories. Positive and negative NTS instances were identified according to validated measurement tools specific for nurses and surgeons. We assessed the relationship between NTS and device-related interruptions after adjusting for potential confounders. RESULTS: A total of 86 device-related interruptions occurred in 48 of 144 operations (33%). They were most frequently classified as device failure (54%) followed by improper assembly (19%) and disconnection (14%). Medians of 1 [interquartile range (IQR) 0-3] and 1 (IQR 0-2) negative NTS instance per operation were demonstrated by nurses and surgeons, respectively. Medians of 28 (IQR 15-38) and 40 (IQR 28-118) positive NTS instances per operation were demonstrated by nurses and surgeons. In a multivariable analysis, a higher frequency of negative NTS instances demonstrated by nurses was associated with device-related interruptions after risk adjustment (Odds Ratio 1.33, p = 0.02). CONCLUSIONS: In elective laparoscopic operations, an increased likelihood of device-related interruptions in the OR was associated with more frequent negative NTS demonstrations by nursing teams.

Development and Evaluation of a Novel Instrument to Measure Severity of Intraoperative Events Using Video Data.

OBJECTIVE: To develop and evaluate a novel instrument to measure SEVERE processes using video data. BACKGROUND: Surgical video data can serve an important role in understanding the relationship between intraoperative events and postoperative outcomes. However, a standard tool to measure severity of intraoperative events is not yet available. METHODS: Items to be included in the instrument were identified through literature and video reviews. A committee of experts guided item reduction, including pilot tests and revisions, and determined weighted scores. Content validity was evaluated using a validated sensibility questionnaire. Inter-rater reliability was assessed by calculating intraclass correlation coefficient. Construct validity was evaluated on a sample of 120 patients who underwent laparoscopic Roux-en-Y gastric bypass procedure, in which comprehensive video data was obtained. RESULTS: SEVERE index measures severity of 5 event types using ordinal scales. Each intraoperative event is given a weighted score out of 10. Inter-rater reliability was excellent [0.87 (95%-confidence interval, 0.77-0.92)]. In a sample of consecutive 120 patients undergoing gastric bypass procedures, a median of 12 events [interquartile range (IQR) 9-18] occurred per patient and bleeding was the most frequent type (median 10, IQR 7-14). The median SEVERE score per case was 11.3 (IQR 8.3-16.9). In risk-adjusted multivariable regression models, history of previous abdominal surgery (P = 0.02) and body mass index (P = 0.005) were associated with SEVERE scores, demonstrating construct validity evidence. CONCLUSION: The SEVERE index may prove to be a useful instrument in identifying patients with high risk of developing postoperative complications.

Assessment of 3-Dimensional vs 2-Dimensional Imaging and Technical Performance Using a Multiport Intraoperative Data Capture and Analytic System for Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass Surgery.

IMPORTANCE: Errors and adverse events occur frequently in health care. Three-dimensional (3-D) laparoscopic systems claim to provide more realistic depth perception and better spatial orientation compared with their 2-D counterparts. OBJECTIVE: To compare the association of 3-D vs 2-D systems with technical performance during laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures using a multiport intraoperative data capture system. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was performed between May and December 2018, with a total of 50 LRYGB procedures performed in an academic tertiary care center; recordings of the operations were evaluated with a 30-day follow-up. All procedures were performed by the same surgical team. EXPOSURE: Surgical teams used 2-D or 3-D laparoscopic systems. MAIN OUTCOMES AND MEASURES: Technical performance was evaluated using the Objective Structured Assessment of Technical Skill and surgical errors and events using the Generic Error Rating Tool. RESULTS: Of the 50 patients who underwent LRYGB procedures, 42 (86%) were women, with a median (interquartile range) age of 42 (35-47) years and a median (interquartile range) body mass index of 46 (42-48), with no significant demographic differences between the groups whose operations were performed using the 2-D and 3-D systems. The mean (SD) number of errors per case was significantly lower in procedures using the 3-D laparoscopic system than in those using the 2-D system (17 [6] vs 33 [2]; P < .001). The mean (SD) number of error-related events was significantly lower in procedures using the 3-D system than in those using the 2-D system (6 [2] vs 11 [4]; P < .001). Mean (SD) Objective Structured Assessment of Technical Skill scores were significantly higher when the 3-D system was used than when the 2-D system was used (28 [4] vs 22 [3]; P < .001). CONCLUSIONS AND RELEVANCE: In this limited sample of LRYGB procedures, the use of a 3-D laparoscopic system was associated with a statistically significant reduction in errors and events as well as higher Objective Structured Assessment of Technical Skill scores compared with 2-D systems.

Nontechnical Skill Assessment of the Collective Surgical Team Using the Non-Technical Skills for Surgeons (NOTSS) System.

OBJECTIVE: To validate the Non-Technical Skills for Surgeons (NOTSS) system for assessment of the collective surgical teams' nontechnical skills after observing recordings of actual OR environment. BACKGROUND: The NOTSS system is a widely accepted tool to measure nontechnical skills of individual surgeons, and has mostly been used in the simulated setting. Surgical procedures are rarely performed by a single surgeon, but by a surgical team of attending surgeons, surgical assistants, and surgical trainees. Therefore, assessment of nontechnical skills may benefit from holistic assessment of the collective surgical teams. METHODS: Five trained participants assessed surgical team and attending surgeon using the NOTSS system after watching ten 20-minute long videos obtained from live OR. A set of reference ratings was provided by a multidisciplinary expert committee. We performed analyses to assess system sensitivity; examine inter-rater reliability of ratings; investigate concurrent construct validity; and assess feasibility and acceptability of using the NOTSS system to measure surgical team performance. RESULTS: There was adequate system sensitivity when comparing participants' and reference ratings. Inter-rater reliability among the participants' ratings was good except for decision-making category. The level of inter-rater reliability was similar when rating teams and attending surgeons. There was strong positive correlation between teams' and attending surgeons' NOTSS ratings at category [Pearson coefficient 0.86, 95% confidence interval (CI) 0.82-0.89] and element levels (0.83, 95% CI 0.80-0.85), demonstrating evidence of concurrent construct validity. The participants felt that the use of NOTSS system to measure teams' nontechnical skills was acceptable and feasible to a fair extent. CONCLUSION: The NOTSS system, although developed for assessment of individual surgeons, is a useful tool for observing and rating surgical teams.

Factors associated with surgeon's perception of distraction in the operating room.

BACKGROUND: Distractions in the operating room (OR) can create stress among surgeons and lead to higher chances of errors and adverse events. The objective is to determine intraoperative factors that are associated with surgeons' perception of distraction. METHODS: We conducted a prospective cohort study in 265 consecutive patients undergoing elective laparoscopic general surgery during the 2 years after the implementation of a data capture system called the OR Black Box to identify intraoperative sources of distraction. At the end of each operation, human-factor surveys were administered to assess whether surgeons felt distracted. Using a multivariable logistic model, we determined which intraoperative sources of distraction were associated with the surgeons feeling distracted in the OR. RESULTS: The attending surgeon reported feeling distracted in 120 of 265 operations (45%). Auditory sources of distraction, such as the OR door opening occurred at a median of 41 times per case (interquartile range (IQR), 32-54). Cognitive distractions such as teaching (142 cases (54%)), device malfunction (91 (34%)), irrelevant conversations (72 (27%)), management of the next case (41 (15%)), and time pressure (22 (8%)) occurred in a significant number of operations. In a multivariable analysis, presence of irrelevant conversations (odds ratio 2.14, 95% confidence interval (CI) 1.16-3.94, p = 0.015) and patient history of previous abdominal surgery (odds ratio 2.2, 95% CI 1.18-4.1, p = 0.013) were independently associated with increased likelihood of the surgeons feeling distracted. CONCLUSIONS: Irrelevant conversation in the OR is a modifiable factor that was independently associated with surgeon's perception of distraction.